Registration

THE HERITAGE SCHOOL

EXTENDED CARE REGISTRATION

2004-2005

Child’s Name____________________________________ Grade:_______________

Parents’ Name(s)_________________________________

List all number(s) where you may be reached:

Mother Father

Home:________________________ Home:______________________________

Work:_________________________ Work:______________________________

Cell: _________________________ Cell: ______________________________

Other: _________________________ Other: ______________________________

Emergency Information (person to contact, if parents cannot be reached):

Name: ____________________ Address: ___________________ Phone:____________

Name:_____________________ Address: ___________________ Phone:____________

OTHER INDIVIDUALS authorized to pick up child(ren) from Extended Care Program:

Name: _____________________ Relationship: _______________ Phone:____________

Name: _____________________ Relationship: _______________ Phone:____________

Name: _____________________ Relationship: _______________ Phone:____________

Name: _____________________ Relationship: _______________ Phone:____________

Parents: Please consider filling out and sending in the Extended Care Registration Form for your child(ren). If a form for your child is on file at the school, you will be able to use the Extended Care Program by calling the Director at 770-253-3484