Family Name__________________________________________________ Home Phone_______________________________________

Address____________________________________________________________________________________________________________

City/State/Zip_______________________________________________________________________________________________________

Mother’s Place of Employment_____________________________________________________________Phone_____________________________________

Email______________________________________________________________Cell Phone_______________________________________

Father’s Place of Employment_____________________________________________________________Phone______________________________________

Email________________________________________________________________Cell Phone_____________________________________

Child is in custody of:       Mother          Father          Both Parents          Other:____________________________________________________

Is anyone restricted from being in contact with your child by court order?________________________________________________________

1. Child’s Name_________________________________________________________Grade___________Birthdate____________
2. Child’s Name_________________________________________________________Grade___________Birthdate____________
3. Child’s Name_________________________________________________________Grade___________Birthdate____________
4. Child’s Name_________________________________________________________Grade___________Birthdate____________

Persons who can be contacted in an emergency and assume responsibility for the child if the parent cannot be reached.

These individuals are also authorized to pick up the child.  Please not identity validation will be required, e.g. driver’s license, etc.

1.  Name______________________________________________________Phone_________________________________________

Address_______________________________________________________Relation to Child_____________________________

2.  Name______________________________________________________Phone________________________________________

 Address_______________________________________________________Relation to Child_____________________________

3.  Name______________________________________________________Phone________________________________________

 Address_______________________________________________________Relation to Child_____________________________

Please list any medical conditions that Clubhouse staff must be aware of, e.g. allergies, asthma, migraines, etc.

Child_________________________________________________Condition______________________________________________

Child_________________________________________________Condition______________________________________________

Clubhouse bills will be issued at the end of each month.

________________________________________________                                ______________________________________________________

Mother’s Name (please print)                                                Father’s Name (please print)

________________________________________________                                ______________________________________________________

Mother’s Signature                                                        Father’s Signature

Return this form and your $25 Annual Registration Fee to the Saint Wenceslaus School Office at 227 Main Street East, New Prague.

Fax (952)758-2958.  Email: sherry.hartman@swsaints.org                                                                                                                           SWS-  June 2021