I, _________________________________, the parent of the following school-age child____________________________, state that the following is accurate:

CHECK ALL THAT APPLY

___  My child is in good health and is able to participate in the center’s planned program. (please note any health                             restrictions____________________________________________________________________________

                            _____________________________________________________________________________________) 

___  My child’s immunizations are up-to-date.

___  My child’s immunizations are NOT up-to-date but a waiver is on file at my child’s school.

___   I give permission for my child to be transported between my child’s public school and The Children's Center, Inc.

         by way of public school transportation or with a center staff member on the Dial-a-Ride vehicle.

___  On rare occasions when public school transportation or the Dial-a-Ride vehicle fails I give my permission for the

        program director to transport my child to or from school.

Parent Signature: _______________________________________________________  Date: ________________________

parent information