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Essential Employee Child Information
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Email
*
Your email
Do you qualify as an "essential employee" as outlined in Governor Hogan's "Interpretive of Guidance"? (See link for details:
https://governor.maryland.gov/covid-19-pandemic-orders-and-guidance/
)
*
Yes
No
Student Name:
*
Your answer
Date of Birth:
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MM
/
DD
/
YYYY
Parent/Guardian Name(s):
*
Your answer
Occupation(s):
*
Your answer
Home Address:
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Your answer
Home Phone:
*
Your answer
Work Phone:
*
Your answer
Cell Phone:
*
Your answer
Email Address:
*
Your answer
The best way to contact you is:
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Your answer
Emergency Contact in case parents cannot be reached:
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Name/Phone Number
Your answer
Intended Start Date
MM
/
DD
/
YYYY
Days of Week Needed
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Monday
Tuesday
Wednesday
Thursday
Friday
Required
Drop off Time (6:30AM-7PM)
Time
:
AM
PM
Pick Up Time (6:30AM-7PM)
Time
:
AM
PM
Allergies:
Your answer
Health Concerns:
Your answer
Is your child taking medication?
*
Yes
No
If yes, please list the medication and dosage.
Your answer
Can your child have his/her picture/video taken and displayed?
*
Yes
No
Is there anything else we should know about your child?
Your answer
I agree that all of the information provided above is accurate
Yes
No
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