EmailMe Form - 2019 Child Safety Package

Child's Information

Student's Name *

First Last

Nickname

Gender *

Boy

Girl

Date of Birth *

MM / DD / YY

Age of Entry *

age in *

months

years

What language does your child speak most often? *

Child is *

Still using diapers

In potty training

Fully potty trained

Will your child have a sibling enrolled? *

Yes

No

If yes, give sibling’s full name and age:

First Last

If yes, give sibling’s full name and age:

First Last

If yes, give sibling’s full name and age:

First Last

Address: *

Street Address City State / Province / Region Postal / Zip Code

Family Information

Person listed as PRIMARY Parent/Guardian will be the sole person authorized to request changes to information and/or cancellation of services.

Primary Parent/Guardian’s: *

Mother

Father

Other

Full Name *

First Last

Occupation

Employer

Mobile Phone *

### - ### - ####

Mobile Phone Provider *

It will allow us to send text messages in case of emergency

Same address as child's? *

Yes

No

Email *

Address: (if different to child’s) *

Street Address City State / Province / Region Postal / Zip Code

Add Secondary Parent/Guardian's *

Yes

No

Crossing Borders cannot legally deny access to or release of a child to either parent/guardian, unless there is an active restraining or court order on file.

1 / 11