New Registration Form

NEW REGISTRATION FORM

Child's Legal Name *

(First, Middle Initial, Last)

Age

Gender

Male
Female

Child's Home/Cell Phone Number

Birth Date

Grade

Child's Address

Mother/Guardian's Name

Father/Guardian's Name

Mother/Guardian's Address

(Street, City, State, Zip)

Father/Guardian's Address

(Street, City, State, Zip)

Child’s Allergies or Restrictions

Medications

* Emergency medications used during the school day are not accessible after school dismisses. Arrangements need to be made with The ZONE Staff to dispense medication.

Special Concerns

(Please list any information that would be helpful in the care of your child.)

Emergency Contact 1 *

Other than Parents

Emergency Contact 2 *

Other than Parents

Relationship to Child

(aunt, uncle, grandparent, etc)

Relationship to Child (copy)

(aunt, uncle, grandparent, etc)

Emergency Contact's Phone Number (copy)

Emergency Contact 1's Work Phone

Emergency Contact 2's Work Phone

Emergency Contact's Phone Number

Child’s Doctor/Clinic Name

Child’s Doctor/Clinic Phone Number

Comment

FIND US:

(402) 316-7037
218 W. Braasch Ave.
PO Box 1032
Norfolk, NE 68701

director@thezoneafterschool.com

(402) 316-7037
PO BOX 1032
228 W. Braasch Ave.
Norfolk, NE 68701

thezoneasp@gmail.com

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