Northshore School District Enrollment Form Page 3
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DAYCARE PROVIDER
Before School
Both Before and After School
After School
:
Provider Name (Last, First) _________________________________________________________________________________________________
Address ________________________________________________________________________________________________________________
Daycare Phone (____) _____________________
Cell Phone (____) ___________________________
Pager (____) _______________________
Comments ______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
OTHER EMERGENCY CONTACTS
(List at least one local Emergency Contact. May list additional Emergency Contacts on the last page.)
First Emergency Contact — Must be local
Last Name __________________________________________________________
First Name _______________________________________
Relationship to Student ________________________________________________
Primary Language __________________________________
Address _________________________________________________________________________________________________________________
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Primary Contact Phone #(____) _______________________
Home
Cell
Unlisted?
Yes
No Email Address ____________________
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2nd Contact Phone #(____) __________________________
Home
Cell
Unlisted?
Yes
No
Second Emergency Contact
Last Name __________________________________________________________
First Name _______________________________________
Relationship to Student ________________________________________________
Primary Language __________________________________
Address _________________________________________________________________________________________________________________
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Primary Contact Phone #(____) _______________________
Home
Cell
Unlisted?
Yes
No Email Address ____________________
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2nd Contact Phone #(____) __________________________
Home
Cell
Unlisted?
Yes
No
SIBLING INFORMATION
(Use a separate sheet for additional siblings.)
Name
Relationship
Age
Gender
School Attending
___________________________________
_________________________
___________
___________
_________________________
___________________________________
_________________________
___________
___________
_________________________
___________________________________
_________________________
___________
___________
_________________________
___________________________________
_________________________
___________
___________
_________________________
MEDICAL / HEALTH INFORMATION
In case of emergency, 911 will be called to evaluate your child. Parent/Guardian will be notified as soon as possible.
Physician Name ______________________________________________
Phone Number (_______) ____________________________________
Dentist Name ________________________________________________
Phone Number (_______) ____________________________________
My child has a life threatening condition that requires a medication or treatment during the school day. ❑ Yes ❑ No
Chapter 28A.210 RCW: Requires orders to be in place before starting school.
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