Folsom Falcon’s Nesting Place

Registration Form (2009-2010)

Please complete and return to Folsom School

Start Date:_______________________________________________________________

First Child: _________________________AGE:_________________GRADE:________

Second Child:________________________AGE:________________GRADE:________

Third Child:_________________________ AGE:________________GRADE:________

SESSIONS:        AM             DAYS:     M   T   W   TH   F

                             PM             DAYS:     M   T   W   TH   F

Parent/Guardian with whom child/children reside:

Name:___________________________Home Phone:_______________Cell Phone:___________________

Mailing Address:

Street: ________________________________________________________________

City:________________________________Zip Code: _________________________

Employer: (mom) _____________________Work Phone: ______________ Cell Phone:_______________

Employer: (dad) ______________________Work Phone: ______________ Cell Phone: _______________

Person(s) Authorized (must show ID) to pick up child/children:

Name:______________________________Work Phone:________________Cell phone:________________

Name: ______________________________Work Phone:_______________Cell phone:_________________

Name:______________________________Work Phone: _______________Cell Phone:_________________

Personal Property Release:  I understand that the FFNP is not responsible for any property belonging to my child/children, which is lost or left at FFNP.

Signature:____________________________Date:___________________________

Emergency Contact: Please give the name, address and phone number of two people that may be notified in the case of an emergency when parents or guardians are not available.  Please provide a telephone number where these people can be contacted during program hours.

Name:__________________________________________________________________

Address:________________________________________________________________

Phone:________________________________Cell Phone:________________________

Name:__________________________________________________________________

Address:________________________________________________________________

Phone:________________________________Cell Phone:________________________

Emergency Medical Release:  If emergency medical care is necessary and I cannot be contacted, I authorize FFNP Staff to act on my behalf in granting permission for my child to receive emergency medical treatment.

Signature:________________________________________Date:_________________

Medical Problems:  Please note below any medical problems or other information that should be brought to the attention of the FFNP Staff:

Medical Insurance Information:

Insurance Company:__________________________Policy No.___________________

A $50.00 non-refundable registration fee must accompany this form for entrance into the FFNP program.  Please make check or money order payable to Falcon’s Nesting Place (No Cash will be accepted).