Child's Name *

First Name

Last Name

Child's Birthdate *

MM

DD

YYYY

Parent/Guardian #1 Name *

First Name

Last Name

Parent/Guardian #1 Cell Phone *

(###)

###

####

Parent/Guardian #2 Name *

First Name

Last Name

Parent/Guardian #2 Cell Phone *

(###)

###

####

Parent/Guardian #1 Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian #2 Address (If resides in a different household)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorized Pick Up Person #1 *

This is a person you authorize to pick up your child.

First Name

Last Name

Authorized Pick-up Person #1 Phone Number *

(###)

###

####

Authorized Pick Up Person #2 *

This person is allowed to pick up your child.

First Name

Last Name

Authorized Pick-up Person #2 Phone Number *

(###)

###

####

Emergency Contact #1 *

In the case of an emergency with your child and we are unable to reach you, we will call this person to update them. They will continue to try to contact you as we tend to your child.

First Name

Last Name

Emergency Contact #1 Phone Number *

(###)

###

####

Emergency Contact #2 *

In the case of an emergency with your child and we are unable to reach you, we will call this person to update them. They will continue to try to contact you as we tend to your child.

First Name

Last Name

Emergency Contact #2 Phone Number *

(###)

###

####

Name of Primary Care Physician *

First Name

Last Name

Primary Care Physician's Phone Number *

(###)

###

####

Name of Child's Dentist *

First Name

Last Name

Child's Dentist's Phone Number *

(###)

###

####

Does your child have any allergies? *

Yes

No

Has your child been stung by a bee? *

Yes

No

Do you authorize Woodstock ASP staff to administer emergency medical care to your child? *

This includes the heimlich maneuver, CPR, and first aid. All staff are required to be First Aid and CPR certified by the American Red Cross.

Yes

No

Do you authorize Woodstock ASP staff to apply sunscreen, bug spray, or medical ointment to your child? *

Sunscreen and bugspray are supplied by the family. Our medical ointment would be bacitracin or neosporin for any cuts/scrapes.

Yes

No

Do you authorize Woodstock ASP staff to accompany your child in an ambluance in case of emergency? *

Yes

No