DCKIDS Permission Slip

CHILDS INFORMATION

DDC KIDS SUMMER Program hours are from 10:00am to 2:00pm. Parent or Guardian MUST be at the Dream Center no later 2:30pm to pick child/children up.

CHILDS INFORMATION

Please fill out the below form to allow your child to attend the DC KIDS Program(s). Each Child will need to have this form filled out individually. If you have more than one child that will be attending, you must complete this form for each individual child.

Child's First Name

Child's Last Name

Date of Birth

Age

Gender:

Male

Female

Address

City

State/Province

Zip/Postal

Grade

School

Race / Ethnicity

PARENT INFORMATION

PARENT & EMERGENCY INFORMATION

Parent / Guardian First Name

Parent / Guardian Last Name

Relationship to Child

Parent Phone

Parent Phone Type

Mobile

Home

Work

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Relation to Child

Emergency Contact Phone

Emergency Contact Phone Type

Mobile

Home

Work

2nd Emerg. Contact First Name

2nd Emerg. Contact Last Name

2nd Emerg. Contact Relation to Child

2nd Emerg. Contact Phone

2nd Emerg. Phone Type

Mobile

Home

Work

#1 Approved Pickup Contact First Name

#1 Approved Pickup Contact Last Name

#1 Pickup Contact Relation to Child

#2 Approved Pickup Contact First Name

#2 Approved Pickup Contact Last Name

#2 Pickup Contact Relation to Child

Medical

MEDICAL & INSURANCE INFORMATION

Allergies

If there none, please enter none.

Physical Impairments or Limitations

If there none, please enter none.

Other Health Issues to be Aware of (illness, etc.):

If there none, please enter none.

Date of last Tetanus Shot

please provide the month and year

Are you covered by hospitalization and medical insurance?

Yes

No

PROVIDER INFORMATION

Policy#

Carrier

Policy Holder's FULL Name

Family Doctor

Family Doctor Phone

Does your Child take any medications?

Yes

No

List Medications

Medication Name

What is the name of the medicine?

Amount

List the amount (example: 100ml, 75mg, 2.5mcg)

Frequency

(Once a Day, 3 Times a Day, etc.)

Add Additional Medication Remove

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CHILDS INFORMATION

CHILDS INFORMATION

PARENT INFORMATION

PARENT & EMERGENCY INFORMATION

Medical

MEDICAL & INSURANCE INFORMATION

PROVIDER INFORMATION

List Medications

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