ZAP Program Registration 2023

Program Options*

Preferred Start Date*

Preferred Start Date - Additional Info

Child's Information

Child's Name*

First Last

Child's Address*

Street Address City Postal Code

Child's Birthdate*

Child's Birthdate

School Attending

Grade

Gender

Parent / Guardian Contact Information

Mother / Guardian*

Name Cell# Work#

Child's Address*

Street Address City Postal Code

Mother / Guardian Email

Email

Parent / Guardian Contact Information

Father / Guardian*

Name Cell# Work#

Child's Address*

Street Address City Postal Code

Father / Guardian Email*

Email

Parent/Guardian with legal custody*

*If there is a custody order please include a copy with your registration

Emergency Contact Information

Emergency Contact (Cannot be Mother or Father, must have a local address)

Emergency Contact Name*

Name Cell# Work#

Emergency Contact Address*

Emergency Contact Address

Emergency Contact Address*

Street Address Address Line 2 City Postal Code

List of People allowed to Pick up your child

Are there any immediate family members that should be denied phone calls with your child?

Additional people who may pick up your child:

Who will pick up child within 30 minutes if they are ill. (Mother, Father, or Emergency Contact)*

Medication Required (epi pen, puffer, etc.)?*

Yes
No

Medication Required Type

Relevant Health information (Medical Condition (s))?*

Yes
No

List Medical Condition(s):*

List Medical Condition(s):

Does your child have any pre-existing conditions that may present as influenza like symptoms? Ex: Allergies, chronic cough, etc*

Yes
No

List pre-existing Condition(s):*

List pre-existing Condition(s):

Is Your Child Immunized?*

Yes
No

Allergies?*

Yes
No

Allergies please list

Dietary restrictions please List

Does your child have any Developmental/Learning (ie. Diagnosed or suspected ADD/ADHD/ODD/Autism/Delays)*

Yes
No

If yes, please indicate details:*

Does your child require any additional assistance?*

Yes
No

If yes, please indicate details:*

Please list any other relevant information:

Cultural Background:

I agree:*

CAPTCHA

Program Registration - ZAP

Child's Information

Parent / Guardian Contact Information

Parent / Guardian Contact Information

Emergency Contact Information