CHILD'S NAME *

First Name

Last Name

Grade Level for 2025-2026 *

PreK

Kinder

1st

2nd

3rd

4th

5th

Child's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Home Phone *

(###)

###

####

Environment *

Allergies

NONE

Food *

Allergies or Intolerances

NONE

Additional special care needs: *

If applicable select all that apply.

NONE

Existing illness

Previous serious illness

Medications prescribed for continuous long-term use

Injuries (past 12 months)

Hospitalization (past 12 months)

Limitation or restriction on child's activities

Reasonable accommodation or modifications

Adaptive equipment

Symptoms or indications of complications

Other

Parent or Guardian #1 Name *

First Name

Last Name

Parent or Guardian #1 Phone *

(###)

###

####

Parent or Guardian #1 Address

If different from child's address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent or Guardian #2 Name

First Name

Last Name

Parent or Guardian #2 Phone

(###)

###

####

Parent or Guardian #2 Address

If different from child's address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Additional Authorized Pick-Up Person #1 Phone *

If no one available, put your number

(###)

###

####

Additional Authorized Pick-up Person #2 Phone

(###)

###

####

May we contact the above people in an emergency? *

Yes

No

Photo Release *

May we use your child's picture for marketing and decoration?

Yes

No

Authorization to seek medical care and/or transport your child to a medical facility. *

I Authorize Red After School Care Program to seek medical care for my child and/or transport them to a medical facility.

I DO NOT Authorize Red After School Care Program to seek medical care for my child and/or transport them to a medical facility. 2

I AGREE to the Policies and Procedures for Red After School Care which can be found here: https://www.redafterschoolcare.org/our-policies-and-procedures *

I AGREE

Right of Parent or Guardian *

A parent or guardian of a child at a childcare facility has the right to: (1) Enter and examine the childcare facility during the facility’s aftercare hours of operation without advanced notice. Parent or guardian will be escorted with either the director or assistant director of Red aftercare. (2) Review the childcare facility’s publicly accessible records. (3) Receive inspection reports for the childcare facility and information about how to access the facility’s online compliance history if requested. (4) Obtain a copy of the childcare facility’s policies and procedures. (5) Review, at the request of the parent or guardian, the facility’s: (A) staff training records; and (B) any in-house staff training curriculum used by the facility. (6) Review the childcare facility’s written records concerning the parent’s or guardian’s child. (7) Have the childcare facility comply with a court order preventing another parent or guardian from visiting or removing the parent’s or guardian’s child. (8) Be provided the contact information for the childcare facility’s local Child Care Regulation office if requested. (9) File a complaint against the childcare facility by contacting the local Child Care Regulation office; and (10) Be free from any retaliatory action by the childcare facility for exercising any of the parent’s or guardian’s rights.

I have been made aware of these rights.

Today's Date *

MM

DD

YYYY