Please complete this form prior to the first class. Please log in to the website for pre-populated webform fields. An advantage of owning an Chesterbrook PTA Website Account/Profile is that webforms and Chipmunk Avenue orders are easier to complete because, assuming you are logged-in to the website, many of the form fields are pre-populated for you. If you are not logged-in and the funny looking stuff in some of the fields is disconcerting, just delete them.

Chipmunk Avenue Order Number:

Please enter the Order Number.

#1 Child's LAST Name, FIRST Name: *

#1 Child's Grade-Teacher: * select...K - Jorgensen AMK - Wynne AMK - Jorgensen PMK - Wynne PM1 - Dillman1 - Hauser1 - Kelly2 - Barker2 - Butler2 - Shivers3 - Antignano3 - Chang3 - Friedman3 - Scholla4 - Keefer4 - Micocci4 - Murphy4 - Vallath5 - Berry5 - He5 - Myren6 - Brown6 - Dickerson6 - MischX - N/A

#1 Child's After-School Activity: * select...Art Session 12:55 PMArt Session 3:05 PMDrama TuesdaysDrama FridaysYoga WednesdaysYoga Thursdays

#2 Child's LAST Name, FIRST Name:

#2 Child's Grade-Teacher: select...K - Jorgensen AMK - Wynne AMK - Jorgensen PMK - Wynne PM1 - Dillman1 - Hauser1 - Kelly2 - Barker2 - Butler2 - Shivers3 - Antignano3 - Chang3 - Friedman3 - Scholla4 - Keefer4 - Micocci4 - Murphy4 - Vallath5 - Berry5 - He5 - Myren6 - Brown6 - Dickerson6 - MischX - N/A

#2 Child's After-School Activity: select...Art Session 12:55 PMArt Session 3:05 PMDrama TuesdaysDrama FridaysYoga WednesdaysYoga Thursdays

#3 Child's LAST Name, FIRST Name:

#3 Child's Grade-Teacher: select...K - Jorgensen AMK - Wynne AMK - Jorgensen PMK - Wynne PM1 - Dillman1 - Hauser1 - Kelly2 - Barker2 - Butler2 - Shivers3 - Antignano3 - Chang3 - Friedman3 - Scholla4 - Keefer4 - Micocci4 - Murphy4 - Vallath5 - Berry5 - He5 - Myren6 - Brown6 - Dickerson6 - MischX - N/A

#3 Child's After-School Activity: select...Art Session 12:55 PMArt Session 3:05 PMDrama TuesdaysDrama FridaysYoga WednesdaysYoga Thursdays

#4 Child's LAST Name, FIRST Name:

#4 Child's Grade-Teacher: select...K - Jorgensen AMK - Wynne AMK - Jorgensen PMK - Wynne PM1 - Dillman1 - Hauser1 - Kelly2 - Barker2 - Butler2 - Shivers3 - Antignano3 - Chang3 - Friedman3 - Scholla4 - Keefer4 - Micocci4 - Murphy4 - Vallath5 - Berry5 - He5 - Myren6 - Brown6 - Dickerson6 - MischX - N/A

#4 Child's After-School Activity: select...Art Session 12:55 PMArt Session 3:05 PMDrama TuesdaysDrama FridaysYoga WednesdaysYoga Thursdays

Parent's LAST Name, FIRST Name:

Spouse's LAST Name, FIRST Name:

Email Address: *

Home Phone: *

Work Phone:

Mobile Phone:

After-School Activity Policies: *

Yes

Have You Read The Chesterbrook PTA After-School Activity Policies? If not please click on the link and do so. It includes important information about pick-up and drop-off instructions.

Emergency Contact #1: *

LAST Name, FIRST Name

Emergency Contact #1 Phone Number: *

Emergency Contact #1 Additional Phone Number:

Emergency Contact #2: *

LAST Name, FIRST Name

Emergency Contact #2 Phone Number: *

Emergency Contact #2 Additional Phone Number:

Names of People You Do NOT Want To Pick-Up Your Child(ren):

Please provide the name(s) and description(s) of anyone who you do NOT want to pick-up your child(ren).

Health Care Provider: *

Please provide the name and telephone number of your health care provider.

Health Insurance Information: *

Please provide the name and phone number of your health insurance company.

Emergency Care Authorization: * select...YesNo

Authorization for the student to be transported to the emergency room and authorization fpr the hospital staff to provide treatment.

Special Instructions:

Please provide any additional information, e.g., SACC enrollment, allergies, physical limitations.