I. Child's Name Gender Male Female Select Gender Grade Kindergarten 1st 2nd 3rd 4th 5th 6th Select Grade II. Child's Name II. Gender Male Female Select Gender II. Grade Kindergarten 1st 2nd 3rd 4th 5th 6th Select Grade III. Child's Name III. Gender Male Female Select Gender III. Grade Kindergarten 1st 2nd 3rd 4th 5th 6th Select Grade IV. Child's Name IV. Gender Male Female Select Gender IV. Grade Kindergarten 1st 2nd 3rd 4th 5th 6th Select Grade Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Africa / Canada / Europe / Middle East Armed Forces Ameroca (Except Canada) Armed Forced Pacific Select State Zip Code Phone Email Intended Child Care Schedule (please check one) Before Care AM Session only Before Care and After Care AM & PM Sessions After Care PM Session only Emergency Drop off Parent/Guardian Information I: I. Parent/Guardian Name Cell Phone # Home Phone # Work Phone # I. Parent/Guardian Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Africa / Canada / Europe / Middle East Armed Forces Ameroca (Except Canada) Armed Forced Pacific Select State Zip Code I. Parent/Guardian Employer Email Parent/Guardian Information II: II. Parent/Guardian Name Cell Phone # Home Phone # Work Phone # II. Parent/Guardian Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Africa / Canada / Europe / Middle East Armed Forces Ameroca (Except Canada) Armed Forced Pacific Select State Zip Code II. Parent/Guardian Employer Email Please check below if you have a court order that would prevent anyone from removing your child from the program. The PAC Before and After School Program Must have a copy of this document in order to enforce it. Yes, I have provided PAC with a court order that would prevent anyone from removing my child from the program. Emergency Local Contact (not a parent). Please provide at least two (2): I. Name Phone # II. Name Phone # Additional Authorized People for Pickup 1. Name Phone # 2. Name Phone # 3. Name Phone # 4. Name Phone # Medical Information: Child’s Doctor Doctor’s Phone Number Name of Insurance Company Name of Policy Holder Insurance ID Number Relationship Please provide us with any information that you feel would be useful in meeting your child’s needs including medical information such as asthma, allergies, diabetes or any other medical conditions or special needs: I understand that if emergency medical care is necessary by a physician and I cannot be contacted, I authorize the Principle Academy Charter childcare provider to act on my behalf in granting permission for my child, named above, to receive treatment as follows: Any child experiencing illness will be attended by a PAC Before and After Care Program childcare provider. The parent or emergency contact will be contacted. In the event of a serious injury, an ambulance will be called first. This will be followed by a call to the child’s parent or the emergency contact. The childcare provider will then accompany the child until the arrival of a parent or emergency contact. PAYMENT Cost: Before Care $5/child; After Care $10/child - Discount provided for multiple children in the same household. One-time registration fee: $15 - Registration fee is due on Monday, September 20th PAC accepts checks or money orders only as payment for the PAC Before and After Care Program. Print/Sign Name: Submit