Date of Birth

MM

DD

YYYY

Child's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father Parent / Guardian Name

First Name

Last Name

Home Phone

(###)

###

####

Address (if different from child's)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Work Phone

(###)

###

####

Home Phone

(###)

###

####

Address (if different from the child's)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

For any child with health care needs such as allergies, asthma, or other chronic conditions that requirespecializedhealth services, amedical action plan shall be attachedto the application. Themedical action plan must be completed by the child's parent or health care professional. Is there Medical action plan atached?

Yes

No (Medical action plan must be updated on an annual basis and when changes to the plan occur)

Office Phone

(###)

###

####

Hospital Phone

(###)

###

####