EnrichTheKids, Inc.
“Start today for an enriched tomorrow!”
Payment Schedule: weekly monthly other______________
(circle one, this will be the payment cycle you will be espected to adhere to unless prior arrangements are made with your site director)
School Child Attends___________School Year 09/10 grade _______teacher ___________
Student Name ___________________________Date of Birth ___________________
e-mail address_________________________________________________________
Home Address ________________________________________________________
Parents Address (if different)________________________________________________
Home Phone _________________
Guardian 1 __________________phone: work _____________home________________
Employer-______________________Employment Address______________________
Cell Phone/Pager_________________
Guardian 2 _________________ phone: work _____________home____________
Employer_______________Employment Address___________________________
Cell Phone/Pager_________________
Student lives with: ________________________________________________________________
Persons Authorized to Pick Up Child in Preference Order and additional Emergency Contacts
Name ______________Relationship _________work #___________home#____________
Address_________________________________________________________________
Name ________________Relationship _______work #___________home#___________
Address_________________________________________________________________
Name ________________Relationship _______work #___________home#____________
Address_________________________________________________________________
Name ________________Relationship _______work #___________home#___________
Address_________________________________________________________________
Medical Information
Does your child have limitations due to physical, medical, vision, and/or hearing needs?
Explain________________________________________________________________
List any allergies ________________________________________________________________
List your child’s medication’s _______________________________________________________
If your child requires administration of medication during program hours, please consult with the
Program Director or Site Director prior to attendance.