Child's Name:  

Date of Birth:

Parent / Guardian Name/s:

Street

City

State

Zip code

Parent / Guardian – Phone Numbers

Child'sDoctor

List anyone other than parents who has permission to pick up your child and their phone numbers:

In the event of an emergency I give Spring Street Community Care & Recreation Inc. staff permission to obtain health care for my child.

Parent / Guardian  Digital Signature

Today's Date

Your Email Address