Students Name * First Name Last Name Parents Email * Date of Birth * MM DD YYYY Student's Address, City, Zip * Please list everyone authorized to pick up your child and phone number. Additions or deletions must be made in writing to your child's teacher or Director. * Is your child leaving at 12:30 or 1:30 * 12:30 1:30 Fathers Name Fathers Cell Phone # * (###) ### #### Father's Place of Employment * Father's Work Phone # (###) ### #### Mother's Name * Mother's Cell Phone # * (###) ### #### Mother's Place of Employment * Mother's Work Phone # * (###) ### #### Any known allergies or medical conditions? * Yes No Please specify if yes Health Insurance Provider * Child's Doctor's Name * Doctor's Phone # * (###) ### #### Immunizations up to date? Please provide a copy to keep on file. * Yes No Where do you attend church? * I attend Thrive. I attend another church. I do not have a home church. Thank you! PARENT FORMRelease Authorization Form 2023-24Emergency Medical Information 2023-24
