DDCES Aftercare Registration Form

STUDENT INFO  
Name of School   Downtown Doral Charter Elementary  
  Student Name
Student ID
Age     Grade
Gender Dob / /
Ethnic Code Teacher

MOTHER'S INFO *if a field is not applicable put a N/A in textbox
Mother's Name
Home Address
Home Phone
Work Phone
Cell Phone
Email

FATHER'S INFO *if a field is not applicable put a N/A in textbox
Father's Name
Home Address
Home Phone
Work Phone
Cell Phone
Email

AUTHORIZATION INFO *if a field is not applicable put a N/A in textbox
Person Authorized to pick up Child Care Student #1
Person Authorized to pick up Child Care Student #2
I Authorize my Child to Walk Home

EMERGENCY CONTACT *if a field is not applicable put a N/A in textbox
Contact Name 1
Phone 1
Contact Name 2
Phone 2
Name of Physician
Physician Phone
Preferred Hospital
  In the event on one can be contacted, I give permission for my child to receive emergency medical treatment?
Special Needs/Instructions
Siblings in Program
Consent
 

PAYMENT  
  Name on Credit Card  
 Email for Receipt  
Amount $ 50.00
  Credit Card No
 
Month (MM)
Year (YYYY)
Sec Code
 
  By selecting the "Make Purchase" button, you confirm you have reviewed and agree to the terms of use
 
  If there is a problem please call: (305) 569-2223

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