Plymouth Community Renewal Center, Inc.

Forms

Enrollment Application

Before and After School Program (For school age students only.)
Personal information
Name of student:_______________________________ Age: ______
Date of Birth:_____________ S.S.#______________________
Parent or Guardian:____________________
Home phone number: ______________
In case of emergency call:_______________________Telephone # _________

Medical Information
If your child is to receive medication in the morning or afternoon and you would like for the staff to give the medication to your child; Check ( )Yes ( )No. If yes, please fill out medical waiver form.
List any allergies:__________________________________________________

Parent/Guardian Signature: ______________________________________.

Date: ________________

General Information
List any person we should release your child to_______________________________

Tutoring (If requested by parent only) School:_________________Grade: _______
My child needs help with: __________________________________________________________
Please fill out Tutoring enrollment application.
Parent/Guardian Signature:_________________________ Date:______________________

For office use only________________

Medical Information and Release Form

Plymouth Community Renewal Center, Inc. Medical Information and Release Form

Child name: ______________________________________________________________________ Parent name: _____________________________________________________________________ Home address: ____________________________________________________________________

Emergency contact & phone number:

Doctor:__________________Phone #: ____________

Allergies:________________________Medication allergies:________________

Is child taking medication daily? ____Yes ____No If yes, what medication?_____________________________ How often?_____________________

Is child able to participate in recreational activities? ___Yes ____No _

Medical Release
I, _________________________________(name of parent/guardian) hereby give the staff of Plymouth Community Renewal Center, Inc. permission to administer medication to my child. I release and exempt any/all staff from liability should any side effects occur upon administering medication to my child.

Emergency Release
In case of emergency, I _______________________________________ (parent/guardian) hereby give the staff of Plymouth Community Renewal Center, Inc. permission to seek the necessary emergency medical care for my child.

Office Use Only ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________THIS FORM SHOULD ALWAYS ACCOMPANY STAFF WHEN ON FIELD TRIPS.