VUOTS Summer enrichment

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COVID-19

Victoria Urban Outreach Tutoring Service

VUOTS Summer Enrichment Registration

Once you submit this form and pay the registration Fee you Child(s) Space will be held.

Child Name*

Address*

Date of Birth *

Gender *

Grade*

Parent/Guardian 1*

MrsMs.Mr

Parent Name*

Home Address*

Cell Phone*

Home Phone*

Work Phone*

Email Address*

Occupation*

Employer *

The Child lives with ?*

Parent /Guardian 2

MsMrsMr

Parent/ Guardian Name

Home address

Cell Phone

Home Phone

Work Phone*

Email Address *

Occupation*

Employer*

Person Responsible for Payment *

Emergency Contact - Alternative Pickup/Release

Name *

Address*

Email Address *

Cell Phone

Work Phone*

Email Address

Relationship to Child *

Emergency Contact 2

Name

Address

Cell Phone

Work Phone

Email Address

Relationship to child

Please list any additional individuals that. you give permission to pick up your child(s)

Person 1 Person 2 Person 3

Medical Release information

Medical insurance Information

Name of Health Care Provider *

Name of Primary Care Physician, Address & Phone number*

Hospital Preference *

If so where?

yesno

Please list any medical conditions, including those that require routine Maintenance or medication (Ie..Diabetes, Asthma) *

Is your child(s) currently being treated for any injuries or sickness*

If yes, please explain

YesNo

Is your Child(s) allergic to any medications or food *

If yes, please explain

YesNo

Does your Child require a special diet*

If yes, please explain

YesNo

In Case of medical Emergency Contact *

Contact 1 Contact 2 Contact 3

I understand that I will be notified in case of a medical emergency involving your child. In the event that you cannot be reached, We ask that you authorize the calling of a doctor. In addition to the providing of any medical services in the your child is injured or becomes ill. *

Parent/Gaurdian please initial and date

Will your child attend for both weeks or one?*

Photo Release Form *

I hereby give my permission for my child to be photographed during VUOTS Summer Enrichment Program. I understand the phone will reused to keep wa journal of activities, to share during power point presentation, candor reports to our donors and for promotional purposes including flyers, brochures, newspaper and our website/internet. I understand that although my Child's photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation. Lastly you acknowledge the that all the photo taken are property of VUOTS.

Transportation Release Form*

I hereby give permission for the transportation of my child for official VUOTS activities by modes of transportation agreed to by the program director

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Pay Registration Fee

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