Midway After-School Child Care Program

PANTHER KIDS ENROLLMENT 2014-2015

Midway After-School Child Care Program

Campus___________________

Please complete the information below for each child in your family you wish to enroll in Panther Kids. Forms and $25 enrollment fee (one per family) can be dropped off at your child’s school or the Midway Administration Building or they can be mailed to MISD, 13885 Woodway Dr., Woodway, TX 76712.

1. Child’s Last Name ________________________ First ______________________ Middle Initial _____

Age on 9/1/14 ______ Grade 14-15 ______ Qualified Free/Reduced Lunch? __________

2. Child’s Last Name ________________________ First ______________________ Middle Initial _____

Age on 9/1/14 ______ Grade 14-15 ______ Qualified Free/Reduced Lunch? __________

3. Child’s Last Name ________________________ First ______________________ Middle Initial _____

Age on 9/1/14 ______ Grade 14-15 ______ Qualified Free/Reduced Lunch? __________

Parent Information

Family Residence Address _________________________________________________________________

City, State, and Zip _______________________________________________________________________

Father’s Name _______________________________ Place of Work ________________________________

E-mail Address:____________________________________________________________

Work Phone __________________ Home Phone _________________ Cell Phone ____________________

Mother’s Name _______________________________ Place of Work _______________________________

E-mail Address:____________________________________________________________

Work Phone __________________ Home Phone _________________ Cell Phone ____________________

Name of Person(s) Financially responsible for Panther Kids tuition_________________________________

Emergency Contact Name ________________________________

Work Phone _________________ Home Phone _________________ Cell Phone _____________________

In the event of a medical emergency and I cannot be reached, I authorize the proper Midway officials to administer appropriate

first-aid and, if necessary, call 911 for emergency medical care and possible transport by ambulance to a hospital. I assume all responsibility for medical expenses incurred.

__________________________________________________________ ______________________

Signature of Parent/Guardian—Admission to Panther Kids will not be considered without a signature. Date

-OVER-

Panther Kids Pick Up Information

Please list all persons who are authorized to pick up your child from Panther Kids,

After-School Program. We are assuming parents listed on enrollment form can pick up.

Name Relationship Contact Phone #’s

1. ________________________ __________________ Work________________

Home________________

Cell________________

2. ________________________ __________________ Work________________

Home________________

Cell________________

3. ________________________ __________________ Work________________

Home________________

Cell________________

4. ________________________ __________________ Work________________

Home________________

Cell________________

5. ________________________ __________________ Work________________

Home________________

Cell________________

6. ________________________ __________________ Work________________

Home________________

Cell________________

7. ________________________ __________________ Work________________

Home________________

Cell________________

8. ________________________ __________________ Work________________

Home________________

Cell________________

3-24-14 DR