LAST NAME Child’s Name Address Phone Emergency Contacts & Parents’ Name Numbers Phone Numbers Check In/Out Form Afterschool 3rd-4th Today’s Date: Dec. 12, 2018
Child’s Name Check In Check Out Comments
Child Record Summary Lab _____ Supervisor ____________________ “R” Children Preschool Immun. Immun. Insurance Indemni- Emergency Photo Parent Parent Allergies/Health Concerns Record Deficient Inform. fication Contact Consent Involve- Involve- Other Information/ Comments Clause Informatio Option ment ment Signed n Provided Option Completed X=completed List them X=have X=completed X=completed List number List number Date X X X --- --- X X X X X X X X X X X X X X X X X X X X Gluten intolerant X X X X X X X X X X X X X X X X X X X X X --- X X X --- X X X X X --- --- --- --- Asthma X X X X X X X X X X X X X X X X X X X X X X X X Lactose Intolerant Testing for celiac No grapes unless wash well Self-esteem issues X X X X X X X X X X --- --- X X --- --- X X X X X X X X X --- X X X X X X X X X X X X X X X X
Converter Name XL Tubes Sep/19 Date Order ID GSM Size A X Size B Mode Height Reams X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X