Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Child's Primary Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent 1 *

First Name

Last Name

Parent 1 Phone Number *

(###)

###

####

Parent 2

First Name

Last Name

Parent 2 Phone Number

(###)

###

####

Child Lives With *

Both Parents

Parent 1

Parent 2

Parent Marital Status *

Married

Divorced

Other

Medical/ Personal Information *

Please check all that apply so that we can better assist your child. *Please note, Old School may not be able to accommodate certain needs. If you have questions about whether we are equipped to work with your child, please contact us at 713-510-3102.

Asthma

Allergies

ADHD/ ADD

Aspergers

Autism

Dyslexia

Dysgraphia

Behavioral Issues

Section 504 Accommodations

Special Education*

None

Emergency Contact 1 *

First Name

Last Name

Emergency Contact 1 Phone Number *

(###)

###

####

Emergency Contact 2

First Name

Last Name

Emergency Contact 2 Phone Number

(###)

###

####

Media Release *

Old School may at any point take photographs or video of our program at work for such purposes as publicity, illustration, advertising, and web content. I grant Old School LLC and it's representatives and employees permission to take such photographs or videos of my child.

I agree

Parent Permission *

Old School ASC will be planning recreational activities for my child and screen a movie for kids on occasion. All movies shown are PG or G rated. If you object to your child watching or specific content please notify your site director in writing. I hereby grant Old School permission to plan daily activities for my child to take part in and to screen movies for my child.

I agree

Medical Authorization & Permission to Treat *

I hereby grant Old School ASC permission to take whatever action in its judgement may be necessary in supplying emergency medical services to the named child. I understand that, consistent with the circumstances of the situation and available time, Old School ASC will make every effort to contact and follow the instructions of the parent or legal guardian. I hereby Agree that I will be solely responsible for and will pay promptly any expenses which may be incurred by Old School ASC in making emergency medical treatment to named child.

I agree