PORTSMOUTH SCHOOL DEPARTMENT

CHILD/DAY-CARE PROVIDER INFORMATION

Student’s Name: _____________________________________ Date: ________________

Will this student be coming to school from a child/day-care provider? ___ No ___Yes

If yes, please complete the following:

Student will be arriving at school from provider: … Everyday (if not everyday, check appropriate days):

… Monday … Tuesday … Wednesday … Thursday … Friday

Child/Day-Care Provider’s Name: _________________________________________________________

Child/Day-Care Provider’s Address: _______________________________________________________

Child/Day-Care Provider’s Phone Number: _________________________________________________

Will this student be returning from school to a child/day-care provider? ___ No ___Yes

If yes, please complete the following:

Student will be returning from school to provider: … Everyday (if not everyday, check appropriate days):

… Monday … Tuesday … Wednesday … Thursday … Friday

Child/Day-Care Provider’s Name: _________________________________________________________

Child/Day-Care Provider’s Address: _______________________________________________________

Child/Day-Care Provider’s Phone Number: _________________________________________________

ADM-05-01

PORTSMOUTH SCHOOL DEPARTMENT

CHILD/DAY-CARE PROVIDER INFORMATION

Student’s Name: _____________________________________ Date: ________________

Will this student be coming to school from a child/day-care provider? ___ No ___Yes

If yes, please complete the following:

Student will be arriving at school from provider: … Everyday (if not everyday, check appropriate days):

… Monday … Tuesday … Wednesday … Thursday … Friday

Child/Day-Care Provider’s Name: _________________________________________________________

Child/Day-Care Provider’s Address: _______________________________________________________

Child/Day-Care Provider’s Phone Number: _________________________________________________

Will this student be returning from school to a child/day-care provider? ___ No ___Yes

If yes, please complete the following:

Student will be returning from school to provider: … Everyday (if not everyday, check appropriate days):

… Monday … Tuesday … Wednesday … Thursday … Friday

Child/Day-Care Provider’s Name: _________________________________________________________

Child/Day-Care Provider’s Address: _______________________________________________________

Child/Day-Care Provider’s Phone Number: _________________________________________________

ADM-05-01