Extended Care Authorization Form
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1AARON FAMILY JEWISH COMMUNITY CENTER
EXTENDED CARE AUTHORIZATION
Camper’s Name_____________________ Grade____ Camp(s)__________________
Address___________________________City__________________Zip_________
nd
Home Phone________________________ 2
Phone_________________________
Mother’s Name____________________Work #___________ Cell #____________
Father’s Name_____________________ Work #__________ Cell #____________
Authorization for emergency & pick up, when parent cannot be reached:
Name_________________________Work #______________ Cell #____________
Name_________________________Work #______________ Cell #____________
Name_________________________Work #______________ Cell #____________
Important Information for Extended Care Staff to know about your child:
AM Arrival Time: _____________
PM Pick up Time: __________________
Medications/Allergies:
Additional Information:
Parent Signature__________________________________Date________________
Print Parent Name___________________
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Parent category: Legal