Children’s Info .com



0048196500Office Use Only___________________Registration Date_______ Fees Paid __Club ID___________ Receipt # _______New Member / Renewing MemberSchool / Summer00Office Use Only___________________Registration Date_______ Fees Paid __Club ID___________ Receipt # _______New Member / Renewing MemberSchool / Summer Membership Info Sheet Children’s InfoFull NameNicknameBirth DateMonth/Day/YearGenderFemale/MaleSchoolGrade__ /__ /_____F___ M_____ /__ /_____F___ M_____ /__ /_____F___ M_____ /__ /_____F___ M___ Parent Contact InfoParent/Guardian NameStreet AddressCityPhoneEmailRelationship to ChildChildren live at this address: □Parent/Guardian NameStreet AddressCityPhoneEmailRelationship to ChildChildren live at this address: □ Pick UpNames of Persons Authorized to Pick Up Children*Must provide Photo ID*Phone NumberMy Child/Children Can Walk Home:Yes ____ No ____Special Instructions: Health InfoChild’s NameAllergiesOther Medical ConditionsSpecial Instructions:*Note: The Sandy Club, “A Safe Place for Boys and Girls” cannot administer medication or provide other treatments. Health Info (Continued)Child’s NameAllergiesOther Medical ConditionsSpecial Instructions:Child’s NameAllergiesOther Medical ConditionsSpecial Instructions:Child’s NameAllergiesOther Medical ConditionsSpecial Instructions:*Note: The Sandy Club, “A Safe Place for Boys and Girls” cannot administer medication or provide other treatments. In Case of EmergencyNameNumberRelationshipDoctor:Doctor/PhysicianOther:Other: Demographic InformationRace/Ethnicity (please circle one)American Indian or Alaskan NativeNative Hawaiian or Pacific IslanderAsianBlack or African AmericanHispanic or LatinoMiddle EasternWhite or CaucasianOther:Annual Family Income (please circle one)$14,800 and under$14,801 - $24,000$24,001 - $34,000$34,001 - $44,000$44,001 - $54,000$54,001 - $64,000$64,001 and aboveFamily Size:____Single Parent Home:Yes___ No___Children live with:Mother___ Father___ Other___*This information qualifies The Sandy Club, “A Safe Place for Boys and Girls” and its members for federal programs including free meals and the reduction of other fees. All information is regarded as strictly confidential.My child/children may be photographed for Club publicity and promotion:Yes ? No ? ................
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