Application
2007-2008
Child’s Name ____________________________________________________________________
Child’s Birth date ________________________________________ Sex: ___________________
Mother’s Name ___________________________________________________________________
Address/Phone #: _________________________________________________________________
Father’s Name ____________________________________________________________________
Address/Phone #:__________________________________________________________________
Guardian’s Name __________________________________________________________________
Address/Phone #: __________________________________________________________________
Child’s Address ___________________________________________________________________
City/State/Zip – Phone #: ____________________________________________________________
Emergency Phone #1_______________________________________________________________
Emergency Phone #2 _______________________________________________________________
Name of Child’s Physician ___________________________________________________________
Physician Phone Number _____________________________________________________________
Medical Insurance Type: _______________________________ Insurance # ___________________
Dentist ____________________________________________________________________________
Dietary Restrictions and Allergies _______________________________________________________
2 _________________________________________________________________________________
3__________________________________________________________________________________
NOTE: In a serious emergency, your child will be taken to the nearest hospital. Should such action be necessary you will be notified as soon as possible and will be responsible for any charges. Your signature on this application does not give the hospital permission to treat your child.
I consent to Fellows Children’s Academy providing emergency medical treatment to my child
Yes ________ No _________
Child will be delivered by ______________________________________________________________
Child will be picked up by ______________________________________________________________