Child's Name *

First Name

Last Name

Grade Level for 2025-2026 *

PreK

Kinder

1st

2nd

3rd

4th

5th

Child's Birthday Month *

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sept

Oct

Nov

Dec

Child's Day of Birth *

What day of the month was your child born?

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Year of Child's Birth *

2022

2021

2020

2019

2018

2017

2016

2015

2014

Child's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Home Phone *

(###)

###

####

Child's Special Car Needs *

None

Environmental Allergies

Food intolerances

Existing illness

Previous serious illness

Medications prescribed for continuous long-term use

Injuries & hospitalization (past 12 months)

Limitation or restriction on child’s activities

Reasonable accommodation or modifications

Adaptive equipment (include instruction below)

Symptoms or indications of complications

Other

Parent or Guardian #1 Name *

First Name

Last Name

Parent or Guardian #1 Phone *

(###)

###

####

Guardian or Parent #1 Address

If different than the child's address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent or Guardian #2 Name

First Name

Last Name

Parent or Guardian #2 Phone

(###)

###

####

Parent or Guardian #2 Address

If different from the child's

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Additional Authorized Pick-Up Person #1 Phone *

If no one available, put your number

(###)

###

####

Additional Authorized Pick-up Person #2 Phone

(###)

###

####

May we contact the above people in an emergency? *

Yes

No

Photo Release *

May we use your child's picture for marketing and decoration?

Yes

No

Authorization to seek medical care and/or transport your child to a medical facility. *

I Authorize Red After School Care Program to seek medical care for my child and/or transport them to a medical facility.

I DO NOT Authorize Red After School Care Program to seek medical care for my child and/or transport them to a medical facility. 2

I AGREE to the Policies and Procedures for Red After School Care which can be found herehttps://www.redafterschoolcare.org/our-policies-and-procedures *

I AGREE

Right of Parent or Guardian *

A parent or guardian of a child at a childcare facility has the right to: (1) Enter and examine the childcare facility during the facility’s aftercare hours of operation without advanced notice with either the director or assistant director of Red aftercare. (2) Review the childcare facility’s publicly accessible records. (3) Receive inspection reports for the childcare facility and information about how to access the facility’s online compliance history. (4) Obtain a copy of the childcare facility’s policies and procedures. (5) Review, at the request of the parent or guardian, the facility’s: (A) staff training records; and (B) any in-house staff training curriculum used by the facility. (6) Review the childcare facility’s written records concerning the parent’s or guardian’s child. (7) Have the childcare facility comply with a court order preventing another parent or guardian from visiting or removing the parent’s or guardian’s child. (8) Be provided the contact information for the childcare facility’s local Child Care Regulation office. (9) File a complaint against the childcare facility by contacting the local Child Care Regulation office; and (10) Be free from any retaliatory action by the childcare facility for exercising any of the parent’s or guardian’s rights.

I have been made aware of these rights.

Today's Date *

MM

DD

YYYY