Kidstown Drop-In Health Form
For children attending Kidstown and/or Parents Night Out
Child's Name
*
First Name
Last Name
Child's Nickname, if any
Child's Gender
*
Male
Female
Child's Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Child's Grade in Fall 2017
*
Please Select
pre-kindergarten
kindergarten
first grade
second grade
third grade
fourth grade
fifth grade
sixth grade
Does your child have an IEP or 504?
Yes
No
PARENT/GUARDIAN 1 INFORMATION
Parent 1 Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your cell phone will be used as the primary contact for emergency situations. Please make sure this number is current.
Parent 1 Cell Phone Number
*
-
Area Code
Phone Number
Parent 1 Home Phone Number
-
Area Code
Phone Number
Parent 1 Work Phone Number
-
Area Code
Phone Number
We require an email address so you will receive Kidstown notices, including winter storm closures.
Email Address
*
PARENT/GUARDIAN 2 INFORMATION
Parent 2 Name
First Name
Last Name
Parent 2 Cell Phone Number
-
Area Code
Phone Number
Parent 2 E-mail Address
Parent 2 Address (if different from Parent 1 address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
TEXT MESSAGE ALERTS
I permit the SJCC to text the selected people at the phone number(s) on file for alerts and updates. I understand there may be charges from my carrier. Please note, your phone number will only be used for important notifications, it will not be used for day-to-day messages.
Parent 1
Parent 2
Back
Next
PICK-UP PERMISSIONS
Please list those who have permission to pick up your child. Click "save" after each person is entered.
SUNSCREEN
I grant Kidstown staff permission to apply sunscreen to my child.
Please initial
EMERGENCY CONTACT INFORMATION
In the event that parent(s) is/are not available, please list an authorized emergency contact. These contacts will be added to the authorized pick-up list for your child.
Emergency Contact 1
*
First Name
Last Name
Relationship to Child
Cell Phone Number
*
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Emergency Contact 2
First Name
Last Name
Relationship to Child
Cell Phone Number
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Back
Next
HEALTH INFORMATION
Your child's safety is essential to their Kidstown experience. Medical information helps us during emergencies and helps us keep your child safer.
Does your child have any allergies ?
*
yes
no
If yes, please provide details (i.e. peanut allergy-airborne or ingested).
Does your child have any food restrictions (i.e. keeps kosher, is a vegetarian)?
*
no, my child does not have any food restrictions
yes, I would like to tell you about food restrictions for my child
If yes, please provide details.
Please share any ongoing medical issues/concerns you may have.
none
yes, I would like to share some concerns
If yes, please share your medical issues/concerns.
Please share any other information about your child to make their Kidstown experience more comfortable.
Submit
Should be Empty: