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Home > J.A.M. Session Child Enrollment and Health History Form

J.A.M. Session Child Enrollment and Health History Form

Child Information
Name (Last, First, MI)
 Address - Home (Street, City, State, Zip)
 Telephone Number
 Birthdate (mm/dd/yyyy)
 First Day of Attendance

Parent or Guardian - All parents/guardians are permitted to visit unless access is prohibited or restricted by a court order.
Relationship to Child Name Address - Home (Street, City, State, Zip) Telephone Number Work Address or Address Where Reachable While Child is at Facility Telephone Number
Mother
Father
Guardian
Guardian

Persons Authorized to Call for your Child - Provide the information requested for each person authorized to call for your child.
Relationship to Child Name Address - Home (Street, City, State, Zip) Telephone Number Work Address or Address Where Reachable While Child is at Facility Telephone Number

Emergency Contact - List information of person to contact when monther, father or guardian cannot be reached.
Relationship to Child Name Address - Home (Street, City, State, Zip) Telephone Number Work Address or Address Where Reachable While Child is at Facility Telephone Number

Physician or Medical Facility
Name
 Address
 Telephone Number

Authorization
Yes     No     I hereby give my consent for emergency medical care or treatment to be used only if I cannot be reached immediately.
Yes     No     I give permission for my child to participate in field trips and other activities during operating hours.
                             Transported     Walking
 
Signature - Parent or Guardian
(Enter your initials as an electronic signature)		 Date Signed

Check any special medial condition that your child may have.
Food allergies - specify foods
 Non-food allergies - specify
Asthma Diabetes
Epilepsy / seizure disorder Gastrointenstinal or feeding concerns including special diet and supplements
Cerebral palsy / motor disorder Emotional / behavior disorder including ADD or ADHD
Other condition(s) requiring special care - specify.
Triggers that may cause problems - specify
Signs or symptons to watch for - specify.

I have received a JAM Session Handbook. Yes     No
I have been informed of the JAM Session policies and procedures. Yes     No
I agree that it is the responsibility of the staff and parents to keep an open line of communication. Yes     No
I give my permission to have my child's name and picture used for publicity purposes. Yes     No
I understand that JAM Session staff would appreciate a notice for permanent withdrawal. Yes     No

Signature - Parent or Guardian
(Enter your initials as an electronic signature)		 Date Signed
 

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