Summer Care Registration

Family Name

Today's Date

Child #1 Name

Child #1 - Date of Birth

Will Child #1 be attending Summer School at Northern Ozaukee?

Yes

No

Child #2 Name

Child #2 - Date of Birth

Will Child #2 be attending Summer School at Northern Ozaukee?

Yes

No

Child #3 Name

Child #3 - Date of Birth

Will Child #3 be attending Summer School?

Yes

No

Child #4 Name

Child #4 - Date of Birth

Will Child #4 be attending Summer School at Northern Ozaukee?

Yes

No

Father's Name

Father's Cell #

Father's Work #

Father's Email

Father's Street Address

City

State

Zip

Mother's Name

Mother's Cell #

Mother's Work #

Mother's Email Address

Mother's Street Address (if different)

City

State

Zip

Tenative Daily Schedule

Add Daily Time Schedule Here (example: Tuesdays 8am-2pm, Thursdays 7am-5pm)

Please let us know of any weeks you will NOT be attending Summer Care due to family vacations, etc.

SUMMER CARE NON-REFUNDABLE SUPPLY FEE

SUMMER CARE NON-REFUNDABLE SUPPLY FEE

Upon completing this registration form, remit payment to: Divine Savior Catholic School.

Mail to: PO Box 250, Fredonia, WI 53021 or drop it off in the School Office.

$25.00per child
Maximum $50.00 per family

Authorized Person(s):

The people on this list will be the only ones allowed to remove your child from the Summer Care Program, other than the parents. In the event of an emergency or unauthorized pick-up, the parent will be contacted before the child is released.

Please notify the Summer Care teacher if someone other than the parents will be picking up your child.

Name (first & last)

Phone #

Name (first & last)

Phone #

Unusual Medical Conditions or Allergies that you would like us to be aware of:

Emergency Medical Contact

Emergency Medical Treatment

By checking, I realize that in the case of extreme illness or injury, judgment as to what medical attention is needed, if I am unable to be contacted, will be made by the person(s) in charge. Every effort will be made to contact the parent before emergency care is given.

Parent Signature (type your name here):

Date

DIVINE SAVIOR CATHOLIC SCHOOL

SUMMER CARE Registration Form

Summer Care Registration Form