FIRST NAME _______________LAST NAME_______________________

 DOB:  ____/_____/_____ AGE _______ GENDER:  _________________

HOME PHONE (____)______-_______   CELL PHONE (____)______-______

ADDRESS_______________________________________________________

CITY ____________________________  STATE ______ ZIP ____________

WHO DO YOU LIVE WITH?

BOTH PARENTS   MOTHER ONLY   FATHER ONLY GRANDPARENTS OTHER

PLEASE EXPLAIN: ____________________________________________

FATHER’S NAME _______________________ WORK PHONE # (___)___-____

MOTHER’S NAME ______________________ WORK PHONE# (____)____-___

SCHOOL NAME:  ___________________WHAT GRADE ARE YOU IN?  _____ 

WHAT DOES YOU CHILD NEED HELP IN?

MATH                  READING         LANGUAGE ARTS         OTHER  

PLEASE EXPLAIN: ____________________________________________

ETHNICITY:

WHITE    AFRICAN AMERICAN   ASIAN     HISPANIC   OTHER

IS YOUR FAMILY INCOME ABOVE OR  BELOW $10,000?

DO YOU PARTICIPATE IN THE SCHOOL LUNCH PROGRAM? YES  NO

(THIS INFORMATION IS CONFIDENTIAL AND IS NEEDED FOR GRANT WRITING PURPOSES ONLY.  THANK YOU.)

EMERGENCY INFORMATION MUST BE FILLED OUT AND SIGNED BY GUARDIAN.

IN CASE OF AN EMERGENCY, WHOM DO WE CONTACT?

1. EMERGENCY CONTACT

_______________________________________ PHONE (_____)______-________(FIRST AND LAST NAME AND RELATIONSHIP)

2.  EMERGENCY CONTACT

_______________________________________ PHONE (_____)______-________(FIRST AND LAST NAME AND RELATIONSHIP)

IS THIS STUDENT CURRENTLY BEING TREATED FOR OR HAS HAD THE FOLLOWING CONDITIONS? PLEASE CIRCLE ALL THAT ARE APPROPRIATE:

ALLERGIES         ASTHMA         DIABETES        ADD

ADHD                  DISABILITY/SPECIAL NEEDS

SEIZURES         NOSEBLEEDS     HEART CONDITION 

BIPOLAR           HEMOPHILIA       OTHER

PLEASE EXPLAIN: ____________________________________________

MEDICATIONS CURRENTLY TAKING: ______________________________________________________________

IS THERE ANYTHING ELSE MEDICALLY RELATED WE SHOULD KNOW ABOUT? ______

I , THE GUARDIAN, UNDERSTAND THE FOLLOWING:

1. GONZALEZ ED. & REC. COMMUNITY CENTER DOES NOT PROVIDE PRIMARY MEDICAL BENEFITS TO ITS MEMBERS.

2. THE CENTER IS NOT REPONSIBLE FOR ANY THE ACCIDENTAL INJURIES TO ITS MEMBERS.

3. THE CENTER IS NOT RESPONSIBLE FOR ANY PERSONAL INJURIES OR LOSS OF PERSONAL PROPERTY WHILE ON THE PREMISES.

4. THE CENTER IS NOT FINANCIALLY RESPONSIBLE FOR THE EMERGENCY CARE AND/OR TRANSPORTATION FOR THIS MEMBER.

5.  EVERY EFFORT WILL BE MADE TO CONTACT THE PARENTS OF THE MEMBER IN THE CASE OF AN EMERGENCY.  IF THESE EFFORTS FAIL, I (THE GUARDIAN) GIVE MY PERMISSION TO OBTAIN THE NECESSARY TREATMENT FOR MY CHILD.

The Gonzalez Education and Recreation Community Center is pleased to provide you and your family the educational  and recreational programs available FREE OF CHARGE. Lots of fun sports and learning activities will be offered.

In order to better serve and protect you and all our members, you and your parent/guardian must agree to the following:

1.       Proper behavior is expected from you and each and every member. Disrespectful behavior will not be tolerated.

Continued warnings about your actions will result in a phone call to your parents/guardian to pick you up from the center immediately.

2.       A second such event will result in a one day’s suspension from the premises and our program activities.  Continued misbehavior may result in the loss of membership.

3.       Continued misbehavior will result in permanent suspension from the center.

4.       As a member of the Community Center, you agree to respect and take care of all of the sports equipment, books, computers, etc. that you are allowed to use.

5.       All members are required to sign in and out of the center by the parent/guardian.  If a member needs to be picked up early due to an emergency, the parent/guardian must come in to sign the member out.

6.       Proper attire is required at all times.

PLEASE CHECK ONE OF THE FOLLOWING:

1. ___ My child, ___________________________, is allowed to walk home at the appropriate times without an adult.
2. ___ My child is allowed to walk home with his/her older brother/sister/or cousin __________________________________ (name of relative).
3. ___ My child may only be allowed to leave the center with me or the following adults: (identification will be required of those listed below).

             a. ___________________________b._____________________________

             c.___________________________d._____________________________

4. ___ My child rides the bus to the center.

I have read the information above and agree to follow all the stated safety requirements.

______________________________      ________________________________

Parent/Guardian Signature                  Student Signature

mail to: gonzalezcenter1@yahoo.com