Rolling Hills Elementary
Latchkey Registration Form

Student's Name:                                                                                               Sex:                 
Student's Address:                                                                                                                   
City:                                                     State:                                        Zip:                             

Father's Full Name:                                                                                                                  

Father's Address:                                                                                                                     

 Mother's Full Name:                                                                 Phone:  (home)                       

Mother's Address:                                                                    Phone: (work)                         

Please check the appropriate box:         Married c       Separated c      Divorced: c

If divorced, who has legal custody?                                                                                          

In case of an emergency involving your child and you cannot be reached, please list at least
two people who could be contacted:

Name:                                                                          Phone:                                                

Name:                                                                          Phone:                                                

Name:                                                                          Phone:                                                

Please describe any special conditions regarding your child of which we should be aware
 (health problem ie allergies etc.)                                                                                               

Please list below who has permission to pick up this child.

 Please circle the days of the week that your child will be staying for the Latchkey Program.

            Monday           Tuesday           Wednesday.        Thursday          Friday

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