Children, Inc. SAS Summer Care Registration

School Age Services SummerCare Registration

Child 1

Name	Gender	Race	SS#
	Male Female
Birthday	Age	School child attends

Child 2 (if needed)

Name	Gender	Race	SS#
	Male Female
Birthday	Age	School child attends

Are you eligible for:

State Case/Social Worker (if applicable):

Primary Mailing Address and Contact Information:
It is very important that we keep accurate information so that we can reach you in case of an emergency. It is vital that you provide up-to-date contact information. If any of your information changes please contact us at 895-431-2075 and ask for Diana.

Parent/Gaurdian

Last Name	First Name	Employer

Work Phone	Cell Phone	Email

Parent/Gaurdian #2

Last Name	First Name	Employer

Work Phone	Cell Phone	Email

Home Address	County	Home Phone

Emergency Contact 1
other than parent/gaurdian listed above

Last Name	First Name	Primary Phone	Secondary Phone

Emergency Contact 2
other than parent/gaurdian listed above

Last Name	First Name	Primary Phone	Secondary Phone

Please list those authorized to pick up your child

Is there anything we need to know to better serve your child?
(Example: Special physical or emotional needs, behavioral issues, health concerns or allergies.)

Please select the program location:
Please check the dates your child will attend. You must register for at least 2 days per week, unless you are skipping the entire week. Select dates carefully. You are financially responsible for payment of the dates you reserve. There will be no refunds after May 27th.

Week	Monday	Tuesday	Wednesday	Thursday	Friday
5/21			*	*	*
5/28	Memorial Day	*	*	*	*
6/4
6/11
6/18
6/25
7/2			Fourth of July
7/9
7/16
7/23
7/30

*These days offered only at Ockerman Elementary

All children on this form will be registered for the same days. If you have any special notes or changes, please enter them here:

I understand I must provide a current immunization form on the first day of SummerCare 2011 for my child.

By submitting this form, you agree that you have reviewed and consent to the pricing set forth in the Summer Care 2011 informational materials. If you have any questions regarding pricing, or any other issue, please do not hesitate to call us at (859) 431-2075.

All payments can be made online by visiting Children, Inc.'s website. Upon submitting this registration form, your first installment as well as your activity and registration fees are due.