Emerald Hills Private School

Child enrollment Information:      Code word_____________

School______________ Grade________ Teacher__________

Name                    Home Address             Phone

Mother______________________________________________

Father______________________________________________

Guardian____________________________________________

Child's Physician__________________ Phone____________

May the center call another physicial if unable to contact the above (yes) Circle and Initial________

Other persons to be notified in case of illness or accident

Name                         Home Address               Phone

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___________________________________________________

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Persons permitted to remove child: Father  yes  no

                                                               Mother yes  no

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Comments:_________________________________________

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Sig. or person enrolling____________________Date_______