TESTING School Age Registration Form

Emergency Contact Parental Consent Form

55 PA Code Chapters 3270.124(a)(b), 3270.181 & 182, 3280.124(a)(b), 3280.181 & 182, 3290.124(a)(b), 3290.181 & 182

Child's Name*

First Last

Birth Date*

Street Address*

Street Address Address Line 2 City State ZIP Code

Guardian

Guardian's Name / Legal Guardian*

First Last

Relationship to Child*

Home Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Mobile Phone*

Please only insert the number. Do not add any additional text.

Email Address*

Business Name*

Business Phone*

Business Address*

Street Address Address Line 2 City State ZIP Code

Guardian

Guardian's Name / Legal Guardian

First Last

Relationship to Child

Home Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Mobile Phone

Please only insert the number. Do not add any additional text.

Email Address

Business Name

Business Phone

Business Address

Street Address Address Line 2 City State ZIP Code

Emergency Contact

Name*

First Last

Phone # while child is in care*

Name

First Last

Phone # while child is in care

Name

First Last

Phone # while child is in care

Person(s) to whom child may be released

Please enter person(s) OTHER than a parent/guardian with whom child may be released.

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone # while child is in care*

Would you like to add another authorized person?*

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone # while child is in care*

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone # while child is in care*

Name of Child's Medical Provider*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

What is the name of your Health Insurance plan?*

Allergies (including medication reactions)*

Policy Number*

Special Disabilities (if any)*

Medical or dietary information necessary in an emergency situation*

Medication, Special Conditions*

Additional information on special needs of child*

Parents Signature is Required for Each Item Below to Indicate Parental Consent

Obtaining Emergency Medical Care*

ELECTRONIC SIGNATURE – by typing your name in this field, you agree that this signature is the electronic representation of your signature for purposes of this document.

Administration of First-Aid Procedures*

ELECTRONIC SIGNATURE – by typing your name in this field, you agree that this signature is the electronic representation of your signature for purposes of this document.

Walks & Trips*

ELECTRONIC SIGNATURE – by typing your name in this field, you agree that this signature is the electronic representation of your signature for purposes of this document.

Transportation by the Facility*

ELECTRONIC SIGNATURE – by typing your name in this field, you agree that this signature is the electronic representation of your signature for purposes of this document.

Parent Signature

Signature of Parent or Guardian*

ELECTRONIC SIGNATURE – by typing your name in this field, you agree that this signature is the electronic representation of your signature for purposes of this document.

Date*

If you would like to enroll another child, please submit this form and then return to the form and start again. If you have a registered account with ACP, your saved information will be pre-populated

Payment Information

I would like to enroll in AutoPay

If you do not wish to enroll in AutoPay, please create an account or log in to MyProCare.

If this is your first time enrolling with us, please wait until you’ve received your enrollment confirmation email to set up an account with MyProCare. The link you'll need to do so will be included in your confirmation email.

TESTING School Age Registration Form

2022-2023 Registration Form

Step 1 of 3

Tuition Agreement

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Payment Amount

Enrollment Form

Family Information

Child Information

Video / Photo Release

Physical

Flu Vaccination

Emergency Contact Parental Consent Form

Guardian

Guardian

Emergency Contact

Person(s) to whom child may be released

Parents Signature is Required for Each Item Below to Indicate Parental Consent

Parent Signature

Payment Information