The Great Escape 3757 South Ponderosa Drive, Evergreen Colorado 80439 Phone: 303-674-0448 Fax: 303-670-0129 Registration / Student Information Form Today’s Date___________ Please fill in the following information. All sections of this form must be completed as per Co State Licensing Business Phone Cell Phone Student Name (First, Middle, Last) of Parent / Legal Guardian Medical Information Current age Date of Birth Phone Number Home Telephone Number Address Address Phone Number State, Zip Code Address Address if different than above of choice Custodial Care Child is under the care of: Address _____Both parents ______Mother Only Allergies / Other critical medical information Name of Parent / Legal Guardian Relationship Persons Authorized to Pick Up/ Emergency Contacts These are individuals (other than those listed under custodial care) who have permission to pick up my Employer Address child. Please list at least two as it is required by law. Business Phone Cell Phone Relationship Name of Parent / Legal Guardian Phone Number Relationship Relationship Employer Address
The Great Escape 3757 South Ponderosa Drive, Evergreen Colorado 80439 Phone: 303-674-0448 Fax: 303-670-0129 Registration / Student Information Form Today’s Date___________ Please fill in the following information. All sections of this form must be completed as per Co State Licensing Student Name (First, Middle, Last) Current age Date of Birth Home Telephone Number Address State, Zip Code Address if different than above Custodial Care Child is under the care of: _____Both parents ______Mother Only Name of Parent / Legal Guardian Relationship Employer Address Business Phone Cell Phone Name of Parent / Legal Guardian Relationship Employer Address Business Phone Cell Phone of Parent / Legal Guardian Medical Information Phone Number Address Phone Number Address of choice Address Allergies / Other critical medical information Persons Authorized to Pick Up/ Emergency Contacts These are individuals (other than those listed under custodial care) who have permission to pick up my child. Please list at least two as it is required by law. Relationship Phone Number Relationship