330 Hookstown Grade Rd, Moon Twp, PA 15108, (412) 264-9392
2020 - 2021 Study Care Program
Application and Emergency Contact Information
Application Date: [Application-Date] Enrollment Date:[Enrollment-Date]
Participants:
Child #1:
First and Last Name: [Participant-1] Date of Birth: [Participant-1-Birth]
School District and School Name: [District-1]
Medical Conditions, Allergies, Educational Needs:
[Medical-1]

Child #2:
First and Last Name: [Participant-2] Date of Birth: [Participant-2-Birth]
School District and School Name: [District-2]
Medical Conditions, Allergies, Educational Needs:
[Medical-2]

Child #3:
First and Last Name: [Participant-3] Date of Birth: [Participant-3-Birth]
School District and School Name: [District-3]
Medical Conditions, Allergies, Educational Needs:
[Medical-3]

Other Participants:
[Other-Participants]

Mother/Father/Guardian Information:
Name: [Primary-Name] Mother/Father/Guardian: [Primary-Mother-Father-Guardian]
Home Address, Phone Number, Email:
[Primary-Street-Address]
[Primary-City-State-Zip]
[Primary-Telephone]
[Primary-Email]

Employer (if employed):
[Primary-Employer]
[Primary-Work-Street-Address]
[Primary-Work-City-State-Zip]
[Primary-Work-Telephone]
[Primary-Work-Email]

Mother/Father/Guardian Information:
Name: [Secondary-Name] Mother/Father/Guardian: [Secondary-Mother-Father-Guardian]
Home Address, Phone Number, Email:
[Secondary-Street-Address]
[Secondary-City-State-Zip]
[Secondary-Telephone]
[Secondary-Email]

Employer (if employed):
[Secondary-Employer]
[Secondary-Work-Street-Address]
[Secondary-Work-City-State-Zip]
[Secondary-Work-Telephone]
[Secondary-Work-Email]

Insurance Information:
Hospital Insurance: [Insurance]
Insurance Company: [Insurance-Company]
Policy Number: [Policy-Number]
Primary Care Physician: [Physician]
Primary Care Physician Phone Number: [Physician-Number]

Emergency Contacts (if parent(s)/guardian(s) are not available):
Emergency Contact #1:
Name: [Emergency-1]
Phone Number [Emergency-1-Phone]
Address:
[Emergency-1-Street-Address]
[Emergency-1-City-State-Zip]

Emergency Contact #2:
Name: [Emergency-2]
Phone Number: [Emergency-2-Phone]
Address:
[Emergency-2-Street-Address]
[Emergency-2-City-State-Zip]

Authorized To Pick Up Your Child: (Other than parent(s)/guardian(s)):
Authorized Person #1:
Name: [Authorized-1]
Phone Number: [Authorized-1-Phone]
Address:
[Authorized-1-Street-Address]
[Authorized-1-City-State-Zip]
Specify which child(ren) they may pick up:
[Authorized-1-Children]

Authorized Person #2:
Name: [Authorized-2]
Phone Number: [Authorized-2-Phone]
Address:
[Authorized-2-Street-Address]
[Authorized-2-City-State-Zip]
Specify which child(ren) they may pick up:
[Authorized-2-Children]

Digital Signature:
I hereby affirm the information provided above is accurate: [Affirmation]
Today's Date: [Today]
Initials and First/Middle/Last Name (i.e., JDS John Dean Smith):
[Signature]
Form Version Date: 08/14/2020