FISH Membership Application 2012-2013

Familys Last Name: Dads Name: Dads Cell: Dads Work Phone: Familys Base Phone Number: PO Box Address: Moms Name: Moms Cell: Vonage/Magic Jack Number: Housing Area:

Email Address: Emergency Contact Person: Does mom or dad have any allergies? Childs Name Birthday Age Grade Allergies? Contact Number:

I have read the FISH Home School Co-op Registration packet, including General Guidelines, Field Trip and Activity Guidelines, Sick Policy, Statement of Faith and Statement of Purpose. I am in total agreement with each of these and strive to follow them. I understand that I am personally liable for the welfare and education of my child and all children I bring to the Fish Co-op. If I choose to leave my child in the care of another parent at FISH Co-op, I will assume responsibility for that decision. I also agree to have my contact information distributed to other co-op members. This information will not be distributed elsewhere. ________________________________________________________________________________________________ ____________ Parent Signature Date