If you have a registration form on file you do not need to fill out another one.

Potty Trained to 11 years of age – First 60 children accepted

  1. Cost is $15for the first child ($10 for each additional child) and is a first come first serve basis. First 60 children will participate.
  2. ID will be checked at drop off and pick up. The same person must pick up the child(ren).
  3. Send children with a bagged lunch (dinner). Snacks, water, and juice will be provided.
  4. Drop-off starts at 5 p.m. at the back of the school. DoorD3 – you will seethe playground
  5. Pick up is 9p.m.There will be a $5 charge for every 5 minutes you are late after 9:05.
  6. Please complete the application and give the $15 fee (checks written out to RVHS) to one of the secretaries in the main office or bring it when you drop your child off Saturday night.

Please Print Clearly

Contact Person: Deborah Kelley19019 Upper Belmont Place, Leesburg, VA 20176

#304-433-2354

Child’s Name Male  Female

FirstLast

Address

StreetCityStateZip

Home Phone()Date of Birth

Lives with ⃞Mother ⃞Stepmother

NameOccupation

()()

E-Mail AddressWork PhoneCell Phone

Lives with ⃞Father ⃞Stepfather

NameOccupation

()()

E-Mail AddressWork PhoneCell Phone

Language spoken most of the time at home

Siblings Names and Ages

Is there a legal custody agreement in force? Yes No N/A

Emergency Contacts (please provide two contactsother than parents):

Name PhoneRelationship to Child

()

()

Foods my child cannot eat due to allergies*

Severe, life-threatening allergies require an Epi-pen kept on-site and the completion of a special medical information form signed by a doctor (we will provide the form).

* Does your child have an Epi-Pen?  YesNo

Foods my child cannot eat due to dietary/cultural restrictions

Dietary restrictions are NOT the same as foods your child doesn’t like.

If your child has food allergies or food restrictions, we will try to accommodate him/her at snack time. However, if your child has multiple, life-threatening food allergies, you may be asked to provide the snack as well as their bagged lunch.

Child’s NameToday’s Date

()

Doctor’s NamePhoneInsurance CompanyPolicy Number

Please list any special medical or educational care (speech therapy, medical treatment, etc.) your child is currently receiving:

TreatmentLocationDuration

Toileting

Your child MUST be self-toileting—this means he/she must take care of all bowel and bladder functions in the bathroom. Pull-ups are not allowed. If your child has an accident, you may be called to come pick him/her up.

Photographs

Photographs of your child may be taken for our use in preparing materials for competitions, RVHS yearbooks, slide show, etc. Children will not be identified by name.

Emergency Medical Transportation

I give permission for my child to be transported by emergency vehicles if immediate emergency treatment is needed. A RVHS staff member will go to the hospital with the child, and the parent(s) will be called to meet the child and staff person at the hospital. The staff person will remain at the hospital until the parent arrives.

Parent Signature REQUIREDDate