Test Form

Parent/Guardian’s Name*

Email Address*

Child’s Name*

Program: (check one)* HaleHanoverPulaski

Schedule: (check one)*AMPMAM & PMDrop-in

How did you hear about our program? (check one)* WebsiteNewspaperReferralReturning familyFlyerOther
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* Please provide the following information about your child/family. It is required for statistical purposes only because our agency receives state funds. It does not affect your admission to our program in any way.

Family Composition

Total # members in family*
GuardianFoster Parent1 parent2 parent'sWorkingOther
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Federal Programs Participation

TFACCAPJobs FirstOther
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The following are all required. Return completed form with documents to the Program Manager. Incomplete applications will not be processed.

Enrollment Information

Enrollment Date*

Child’s FirstName*

Child’s LastName*

D.O.B

Age*

Gender BoyGirl

Race

Social Sec. #

Address*

City*

State*

Zip-Code*

Health Insurance information

Insurance Company

Primary Doctor’s Name*

Doctor’s Telephone #*

Dentist’s name*

Dentist’s Telephone #*

Guardian 1

Relationship to child*

Last name*

First name*

Address*

City*

State*

Zip-Code*

Home Tel. #*

Cellular #

Work Place & Tel.

Work Address

(if applicable)

Guardian 2

Relationship to child

Last name

First name

Address

City

State

Zip-Code

Home Tel. #

Cellular #

Work Place & Tel.

Work Address

Emergency Contacts ** Contacts must be different than the above guardians. **Must have three emergency contacts.

The following people are authorized to pick-up my child (ren) or be contacted in case of emergency. (Must be 18 or older)

1. Name*

Relationship to child*

Address*

License / I .D. #

Tel:#*

Alternate Tel #

2. Name*

Relationship to child*

Address*

License / I .D. #

Tel:#*

Alternate Tel #

3. Name*

Relationship to child*

Address*

License / I .D. #

Tel:#*

Alternate Tel #

I give permission for First Aid to be administered by an appropriate staff member, to my child (ren): in the event of an emergency. I understand I will be called if my child is ill and needs to be picked up (or an alternate emergency contact, if I cannot be reached). I grant permission for my child to be transported to a hospital by emergency vehicle and to receive emergency medical treatment, at any medical facility, if I am not able to be present.

I agree that by submitting this application, I am electronically signing the application.
I,

, solemnly declare that the information I have provided is true and that the documents I am submitting in support of my application are genuine and have not been altered in any way.