St. James Day School Health and Permissions Form
Please take a moment to complete this form in full. This form must be completed for each child individually and submit a current copy of your child’s immunization record.  Both must be completed and in hand at St. James Day School by August 19th, 2022. Mail Immunizations to:
SJDS
ATTN:  Ansley Trask
25 S. 3rd Street
Wilmington, NC  28401

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Child's First Name *
Child's Middle Name
Child's Last Name *
Child's Gender
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Child's Date of Birth *
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DD
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YYYY
Family Mailing Address
Parent or Guardian 1 First Name
 *
Parent or Guardian 1 Last Name
 *
Parent or Guardian 1 Phone Number
 *
Parent or Guardian 1 Email Address
 *
Parent or Guardian 2 First Name
Parent or Guardian 2 Last Name
Parent or Guardian Phone Number
Parent or Guardian 2 Email
Non-Parent Emergency Contact 1 (Full Name) *
Non-Parent Emergency Contact1  Phone Number *
Non-Parent Emergency Contact 2 (Full Name) *
Non-Parent Emergency Contact 2 Phone Number *
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