School Information

Reading Level

Math Level

Name of School

Area(s) of Weakness

Math

Reading

ELA

Other

Parent/Guardian Information

Parent First Name

Parent Last Name

Home Phone Number

Emergency Phone Number

Does the CAPS Tutorial have permission to take and use photos of your child for the purpose of the programs posting on social media.

Yes

Emergency Contact Form

Participant's First Name

Participant's Last Name

Birthdate

Parent/Guardian First Name

Parent/ Guardian Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Number to Call in Emergency:

Parent/Guardian place of employment:

Address (Street, City, State)

Work number

Family Doctor

Family Doctor Number

Family Doctor Address

In the event of an emergency, I hereby give permission to transport my child to a hospital by car or ambulance for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, transport my child to:

Medications:

Check all that apply:

No medication of any type whether prescription or nonprescription may be administered to my child.

No medication of any type whether prescription or nonprescription may be administered to my child unless the situation is life-threatening and emergency treatment is required.

I hereby grant permission for nonprescription medication to be given to my child if they become ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea such as aspirin, throat lozenges, and cough syrup.

Allergies: Special Medical Information: Allergic reactions (medication, foods, plants, insects, etc.)

Vaccinations/Shots are up to date:

Most recent date of tetanus shot

You should be aware of these known medical conditions of my child:

Signature

Date of signature

All information Must Be Current
You can also apply online.
Go to mtzionofalbany.org

Parent Email Address

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