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DC KIDS Permission Form

CHILDS INFORMATION



Program hours are from 3:00pm to 5:30pm. Parent or Guardian MUST be at the Dream Center by 5:30pm to pick child/children up The DC KIDS After School Program is Monday - Thursday from 3:00pm-5:30pm 



CHILDS INFORMATION

Please fill out the below form to allow your child to attend the DC KIDS Program(s). Each Child will need to have this form filled out individually. If you have more than one child that will be attending, you must complete this form for each individual child.

Gender:
Address
Address
City
State/Province
Zip/Postal

PARENT INFORMATION


PARENT & EMERGENCY INFORMATION

Parent Phone Type
Emergency Contact Phone Type
2nd Emerg. Phone Type

Medical


MEDICAL & INSURANCE INFORMATION

If there none, please enter none.
If there none, please enter none.
If there none, please enter none.
please provide the month and year
Are you covered by hospitalization and medical insurance?

PROVIDER INFORMATION

I, hereby, grant permission to any staff person to provide the following over-the-counter drugs to my son/daughter if requested by my son/daughter (check all that apply):
Does your Child take any medications?

List Medications

What is the name of the medicine?
List the amount (example: 100ml, 75mg, 2.5mcg)
(Once a Day, 3 Times a Day, etc.)

2212 SW 55th St
Oklahoma City, OK 73119

Email:  info@dcokc.org
Phone: 405-634-2615

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 Kids work on homework with the help of mentors, participate in arts, play sports, discuss character traits, and more! So jump in today and contact us about volunteering and as always, thank you for your support!