Application Fee: $5.00

Date Paid:___________

Check No:___________

ST. PATRICK CATHEDRAL SCHOOL, 211 BROADWAY, NORWICH, CT 06360

APPLICATION FORM FOR EXTENDED DAY PROGRAM

CHILD’S NAME:________________________________________________________GRADE:_______

AGE:__________DATE OF BIRTH:_______________STARTING DATE:________________________

MOTHER’S/GUARDIAN’S INFO: FATHER’S/GUARDIAN’S INFO:

NAME:_______________________________ NAME:___________________________________

ADDRESS:____________________________ ADDRESS:________________________________

______________________________________ _________________________________________

HOME PHONE:________________________ HOME PHONE:____________________________

WORK PHONE:________________________ WORK PHONE:____________________________

CELL PHONE:________________________ CELL PHONE:_____________________________

PERSON TO BE CONTACTED IN AN EMERGENCY IF PARENT CANNOT BE REACHED.

NAME:_____________________________________TELEPHONE NO:__________________________

NAMES OF OTHERS TO WHOM YOUR CHILD MAY BE RELEASED (use back of form also)

NAME:____________________________________NAME:_____________________________________

PLEASE CIRCLE THE DAYS YOUR CHILD WILL BE ATTENDING. (Please notify the Extended Day Director in writing of any changes after this form is submitted)

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY OCCASIONALLY

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DOES YOUR CHILD HAVE ANY MEDICAL PROBLEMS THAT WOULD PREVENT HIM/HER FROM PARTICIPATING IN ANY ACTIVITIES? YES_______________NO____________________

PLEASE EXPLAIN:____________________________________________________________________

ANY ALLERGIES? YES (Please list):___________________________NO:___________________

NAME OF PHYSICIAN:_______________________________________PHONE:__________________

It is the policy of St. Patrick’s Extended Day Program, in case of accident or medical emergency, to have the child treated by one of the local physicians if you are not available to take the child to his/her own physician. Also, if necessary, the child may be taken to the hospital. Naturally, if you have a local physician he will be contacted. A sincere effort is made to contact the parents, but this is not always possible. All doctors have “days off” when they are not available. So that your child may receive medical care quickly, we ask you to sign the following:

WE HEREBY GIVE OUR PERMISSION TO THE ST. PATRICK’S EXTENDED DAY PROGRAM STAFF TO HAVE OUR CHILD TREATED BY A READILY AVAILABLE PHYSICIAN AND/OR HOSPITAL IN CASE OF AN ACCIDENT OR MEDICAL EMERGENCY, IF WE , AS PARENTS, ARE NOT AVAILABLE TO TAKE HIM/HER TO OUR OWN DOCTOR.

SIGNATURE OF PARENT/GUARDIAN:_________________________________DATE:__________