The Mallory Center

Child's Name:
Parent Name:
Address:
City:
State:
Zip:
Phone:
Neighborhood:
Type of Income:
Amount of Annual Income:
Number in Household:
Marital Status:
Child's Birth Date:
Child's Sex:
Child's Ethnicity:
School Child Attends:
Grade Child is in:
My child has my permission to attend any and on field trips with SAAPS staff, representatives, agents and volunteers.
I will accompany my child on field trips that he or she will attend.
My child has permission to particpate in any project evaluation or survey administered by MCCD staff, representatives. agents or volunteers designed to determine service effectiveness and program impact for the City of Cincinnati. United Way & Community Chest, University of Cincinnati, the State of Ohio. or any SAAPS program funder.
I grant permission for the Mallory Center for Community Development, its staff, representatives, agents and volunteers to use any picture taken of my child while participating in the SAAPS program for any MCCD marketing and promotional projects.
List known allergies:
List any medication your child must take while participating in the SAAPS program.
In case of an emergency, call
Take my child to
My Child's doctor name is

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