Extended Care Registration Please enable JavaScript in your browser to complete this form.Student InformationName of Student *FirstMiddleLastNicknameDate of Birth *Gender *FemaleMaleCurrent Grade *PreKKindergartenFirstSecondThirdFourthFifthSixthSeventhEighthFamily InformationStudent Resides With *Both ParentsMotherFatherShared Custody (1/2 & 1/2)Legal GuardianPrimary Guardian Name *FirstLastPrimary Guardian Relationship *MotherFatherLegal GuardianPrimary Phone *Primary Email *Primary Mailing Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePrimary Occupation & Place of Employment *Primary Work PhoneSecondary Guardian Name FirstLastSecondary Guardian RelationshipMotherFatherLegal GuardianSecondary Phone Secondary Email Secondary AddressSame as PrimaryAdd Secondary AddressSecondary AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSecondary Occupation & Place of Employment Secondary Work Phone Emergency / Medical InformationDoes your child have any allergies? *NoYesPlease list:Does your child take any special medications? *NoYesPlease list medication(s):Does your child have any chronic conditions (asthma, epilepsy, etc.) *NoYesPlease specify: Physician NamePhysician PhoneDentist Name Dentist Phone Preferred HospitalHospital 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? *YesNOEmergency ContactsContact 1FirstLastPhoneContact 2FirstLastPhoneContact 3FirstLastPhoneRelease InformationPlease list any additional people (outside of primary, secondary and emergency contacts) who have permission to pick up your child:Name FirstLastPhoneName FirstLastPhonePlease list names of anyone who DOES NOT have permission to pick up your child:Registration FeePrice: $25.00Please turn in a check to the school office before your child's first day of extended care. Submit
