BURTON P.L.E.A.S.E. Program Registration Form
Child’s Name Grade/HR
Home Address
City State Zip
Home Phone Alternate Phone
Mother’s Name
Cell Phone
Home Address
Home Phone
Work Name & Address
Work Phone
Father’s Name
Cell Phone
Home Address
Home Phone
Work Name & Address
Work Phone
Emergency Contact(s)
Phone
Physician Name and Phone Number
Persons child may be released to:
Does your child have any medical conditions that we need to be aware of?
I have read and agree to all of the Burton International AfterSchool Guidelines.
Parent Signature: Date:
Reg Form _______ Reg Fee ________ Date Paid _______ Staff Initial_______
Child’s Name Grade/HR
Home Address
City State Zip
Home Phone Alternate Phone
Mother’s Name
Cell Phone
Home Address
Home Phone
Work Name & Address
Work Phone
Father’s Name
Cell Phone
Home Address
Home Phone
Work Name & Address
Work Phone
Emergency Contact(s)
Phone
Physician Name and Phone Number
Persons child may be released to:
Does your child have any medical conditions that we need to be aware of?
I have read and agree to all of the Burton International AfterSchool Guidelines.
Parent Signature: Date:
Reg Form _______ Reg Fee ________ Date Paid _______ Staff Initial_______