DRES Before and After School Care Registration Form
2021-2022 Dixon Road Elementary School Before and After School Registration Form
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Email *
Student's Name *
Student's Grade for the 2021-2022 School Year
Teacher for the 2021-2022 School Year (if known)
Will your child need before school care, after school care, or both.
Parent / Guardian email address
Mother's / Guardian's Name
Mother's / Guardian's Cell Phone Number
Mother's / Guardian's Work Phone Number
Father's / Guardian's Name
Father's / Guardian's Cell Phone Number
Father's / Guardian's Work Number
Medical Conditions or Health Concerns (please include any medication that is kept at school).
Emergency Contact Name & Phone Number
Doctor's Name
List any people who are permitted to pick up your child(ren), other than those listed above. Please include their name and phone number. (Please note that these individuals are required to bring in a photo ID to check your child(ren) out. Your chid(ren) will not be permitted to leave the school with anyone other than you or the people listed below.)
I have read and understand all guidelines and procedures outlined in the Before & After School Program. (Your typed name represents your signature.) *
The program may seek emergency medical care for my child in the event that I/we cannot be reached. (Your typed name represents your signature.) *
Do you choose for your student to wear a mask. (We understand that this is subject to change at any time due to changes in the JCPS policy or through your wishes.)
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