Extended Care Registration – St. Vivian Catholic School

Student Information

Name of Student *

First

Middle

Last

Nickname

Date of Birth *

Gender *

Current Grade *

Family Information

Student Resides With *

Primary Guardian Name *

First

Last

Primary Guardian Relationship *

Primary Phone *

Primary Email *

Primary Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Occupation & Place of Employment *

Primary Work Phone

Secondary Guardian Name

First

Last

Secondary Guardian Relationship

Secondary Phone

Secondary Email

Secondary Address

Address Line 1

Address Line 2

City

State

Zip Code

Secondary Occupation & Place of Employment

Secondary Work Phone

Emergency / Medical Information

Does your child have any allergies? *

Please list:

Does your child take any special medications? *

Please list medication(s):

Does your child have any chronic conditions (asthma, epilepsy, etc.) *

Please specify:

Physician Name

Physician Phone

Dentist Name

Dentist Phone

Preferred Hospital

Hospital Phone

Does St. Vivian Extended Care have permission for emergency medical treatment in case of illness or accident if primary contacts and emergency contacts cannot be reached? *

Emergency Contacts

Contact 1

First

Last

Phone

Contact 2

First

Last

Phone

Contact 3

First

Last

Phone

Release Information

Please list any additional people (outside of primary, secondary and emergency contacts) who have permission to pick up your child:

Name

First

Last

Phone

Name

First

Last

Phone

Please list names of anyone who DOES NOT have permission to pick up your child:

Registration Fee

Price: $25.00

Please turn in a check to the school office before your child's first day of extended care.