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| CHARLIE'S PLACE REGISTRATION FORM CHILD'S NAME______________________________________ BIRTH DATE(mm/dd/yyyy)_____________ ADDRESS__________________________________________________________________________________ MOTHER'S NAME/LEGAL GUARDIAN_________________________________________________________ HOME ADDRESS____________________________________________ HOME PHONE_________________ BUSINESS NAME/ADDRESS________________________________________ PHONE_________________ FATHER'S NAME/LEGAL GUARDIAN__________________________________________________________ HOME ADDRESS____________________________________________ HOME PHONE_________________ BUSINESS NAME/ADDRESS________________________________________ PHONE_________________ EMERGENCY CONTACT PERSON(S): NAME ADDRESS PHONE 1._________________________________________________________________________________________ 2._________________________________________________________________________________________ 3._________________________________________________________________________________________ PERSON'S TO WHOM YOUR CHILD MAY BE RELEASED (THIS INCLUDES CARPOOLING) NAME ADDRESS PHONE 1._________________________________________________________________________________________ 2._________________________________________________________________________________________ 3._________________________________________________________________________________________ CHILD'S PHYSICIAN/MEDICAL CARE PROVIDER: NAME____________________________________________________ PHONE_________________________ ADDRESS__________________________________________________________________________________ I HEREBY GIVE MY CHILD PERMISSION TO PARTICIPATE IN ALL PHYSICAL ACTIVITIES AND HEALTH ASSESSMENT PROGRAMS TO BE CONDUCTED AT CHARLIE'S PLACE YES NO (Please circle your response) I HEREBY GIVE CHARLIE'S PLACE PERMISSION TO USE PICTURES OF MY CHILD IN FUTUR NEWSLETTERS ADN PRESS RELEASES YES NO (Please circle your response) PLEASE LIST ANY EXCEPTIONS OR RESTRICTIONS (diabetes, asthma, allergies, pacemaker, heart condition, internal medical device, etc.) SIGNATURE OF PARENT____________________________________________________________________ TODAY'S DATE____________________ |
| PLEASE PRINT OUT AND USE AS MANY COPIES OF THIS FORM AS YOU NEED! |