Columbia Adventist Academy
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Aftercare Registration Form


Aftercare Registration Form

School Year

Student Name
Home Phone #
Mother's Name
Mother's Work #


Father's Name
Father's Work #


Emergency Contact Person
Emergency Contact #
List names of those permitted to pick up your child:
List any allergies or health concerns:  
Doctor's Name

Office Number

Preferred Local Hospital
We, the undersigned parents or legal guardian of the above student, do hereby consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital services that may be rendered. It is understood that reasonable effort will be made to contact the parent/guardian and the doctor listed above before any other physician is called by the school. It is understood that this consent is given in advance of any specific diagnosis or treatment which might be required.

Parent or Legal Guardian Signature   Date
Would you be interested in substituting for one of the Aftercare personnel when the need arises?
Yes No







241 Riverchase Way • Lexington, SC, 29072-9470 • 803-796-0277