Test Form

    HaleHanoverPulaski
    AMPMAM & PMDrop-in
    WebsiteNewspaperReferralReturning familyFlyerOther
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    [/group]

    * 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


    GuardianFoster Parent1 parent2 parent'sWorkingOther
    [group group-familyCompostion clear_on_hide]

    [/group]

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

    Enrollment Information

    BoyGirl

    Guardian 1

    (if applicable)

    Guardian 2

    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)

    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.

    X