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NSKHouston@gmail.com
&
Dechambers2@gmail.com
832-969-5584
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After School (ASK) Summer / Fall Break / Spring Break / Day Camp)
Form 2
Please fill out the form below.
RELEASE AUTHORIZATION
Child’s Full Name and Nickname
*
Date of Birth
*
Month
Day
Year
Age
*
School Attending
Grade
Parents / Guardians Names
*
Address
*
Home Phone
Cell Phone
*
Employer (Mother)
Work Phone
Email
Employer (Father)
Work Phone
Email
Child’s Special Interests
Is there anything we need to know? Ex. ADHD, medication, etc
*
Person(s) to call when, in an emergency, the parent(s) cannot be reached:
Emergency Contact
*
Relationship to the Child
Cell Phone
Work Phone
Other
Emergency Contact 2
*
Relationship to the Child
Cell Phone
Work Phone
Other
Proposed date of admission:
Parent’s Signature
*
Sign in the box or use the keyboard to type.
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Date
*
Month
Day
Year
Submit
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