Parent/Guardian Information

Email *

Address

If different than the child above

Parent/ Guardian #2

Address

If different than child above

Emergency Contact

Emergency Contact #1 Phone *

Emergency Contact #1 Relationship to Child *

Emergency Contact #1 Address *

Emergency Contact #2 Phone *

Emergency Contact #2 Relationship to Child *

Emergency Contact #2 Address *

Enrollment Information

Childcare is Needed for: *

Monday's only when Lockwood R1 is out of school

All Days Lockwood R1 is out of school (This includes Mondays, Fridays & Holiday Breaks)

All Monday's

Only Select Dates (I will Select Below)

Dates I need

Pick Up Authorization

Who may pick up your child besides parent/guardian(s) listed above? *

Note: Please include emergency contacts if applicable. Students will not be released to anyone other than those on this list. Photo identification may be required from anyone other than a parent/guardian

Health Record

Does your child have any food allergies? *

Yes

No

Immunization Record

Click to upload

Every camper is required to have an updated immunization record on file in order to receive care. You may provide this later if you do not currently have it available.

Authorization for Emergency Care *

In the event of an emergency, Mission to Learn Academy LLC has my permission to seek emergency medical attention for my child as needed.

Health Statement *

My child is in good health, is able to participate in group care, has no special health or medical requirements

My child is able to participate in group care but has special health or medical requirements as listed below.

Please list any chronic illnesses, history of hospitalization or anything else the staff would need to know to properly care for your child *

Please write N/A if there are none.

List all medications or modified diets currently being administered to your child *

Please write N/A if there are none.

Credit/Debit Card Agreement *

I HAVE READ AND UNDERSTAND THE CREDIT/DEBIT CARD ON FILE AGREEMENT AND AUTHORIZE MISSION TO LEARN TO CHARGE MY CREDIT/DEBIT CARD THE FEES LISTED ABOVE BASED ON MY SELECTION.

Credit/Debit Card Agreement Signature *

Clear

Policy Agreement and Waiver *

I HAVE READ AND UNDERSTAND ALL POLICIES

Policy Agreement & Waiver Signature

Clear

Transportation & Field Trip Waiver *

I HAVE READ AND AGREE TO THE TRANSPORTATION & FIELD TRIP WAIVER

Transportation & Field Trip Waiver Signature *

Clear