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330 Hookstown Grade Rd, Moon Twp, PA 15108, (412) 264-9392


2020 -2021 Study Care Program

Application and Emergency Contact Information


Please fill out all applicable fields. Fields highlighted in red are mandatory, the application will not submit without these fields completed.

Application Date:
Enrollment Date:

Child #1 First and Last Name:

Child #1 Date of Birth:

Child #1 School District and School Name:

Child #1 Medical Conditions,Allergies, Educational Needs:

Child #2 First and Last Name:

Child #2 Date of Birth:

Child #2 School District and School Name:

Child #2 Medical Conditions,Allergies, Educational Needs:

Child #3 First and Last Name:

Child #3 Date of Birth:

Child #3 School District and School Name:

Child #3 Medical Conditions,Allergies, Educational Needs:

Other Participants:

:
MotherFatherGuardian

Home Address:


Phone Number:

Email:

Employer (if employed):





:
MotherFatherGuardian
First and Last Name:

Home Address:


Phone Number:

Email:

Employer (if employed):






Hospital Insurance? YesNo

























I hereby affirm the information provided above is accurate: Yes
Today's Date:
Initials and First/Middle/Last Name (i.e., JDS John Dean Smith):

Email Address To Send Form Copy:

Form Date: 08/14/2020