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:
Participants:
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:
Mother/ Father/ Guardian Information
:
Mother
Father
Guardian
Home Address:
Phone Number:
Email:
Employer (if employed):
Mother/ Father/ Guardian Information
:
Mother
Father
Guardian
First and Last Name:
Home Address:
Phone Number:
Email:
Employer (if employed):
Insurance Information:
Hospital Insurance?
Yes
No
Emergency Contacts: (if parent(s)/ guardian(s) are not available)
Authorized to Pick Up Your Child: (Other than parent(s)/guardian(s))
Digital Signature:
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
