Give Kids A LIFT! Application

Please return this complete application to:

OUTREACH Any questions? Call: 408/436-2865

926 Rock Ave, Suite 10, San Jose, CA 95131 Fax: 408/382-0470

This demonstration project serves primarily CalWORK’s families. Limited enrollment.

CONTACT INFORMATION

_______________________________________________ ___/___/___ ____________________

Passenger Last Name, First Name Birth Date (m/d/yr) Social Security Number

_____________________________________________ _________________ ______________

^{Home Address Apt. # City Zip}

( )_______________ ______ _______ _______ ____________________

^{Home Phone Weight (pounds) Height Male/ Female Ethnicity (optional)}

________________________________________ _____________________

^{Name of Mother/Legal Guardian Social Security Number}

_____________________________________________ _________________ ______________

^{Home Address Apt. # City Zip}

( ) ____________ ( ) ______________ ( ) ______________ _____________________

^{Home Phone Work Phone Cell/Pager Email}

___________________________________________________________________________________

^{Name and Location of Workplace}

________________________________________ _____________________

^{Name of Father/Legal Guardian Social Security Number}

_____________________________________________ _________________ ______________

^{Home Address Apt. # City Zip}

( ) ____________ ( ) ______________ ( ) ______________ _____________________

^{Home Phone Work Phone Cell/Pager Email}

___________________________________________________________________________________

^{Name and Location of Workplace}

In the event of emergency, when I cannot be reached, I wish one of the following to be notified by

Telephone (do not list the mother/father/guardian). Emergency contacts must be someone nearby

who can be reached quickly. They are authorized to act in my absence, pick up or receive my child.

______________________________________ _____________________________

^{1st Emergency Contact Name Relationship}

_____________________________________________ _________________ ______________

^{Home Address Apt. # City Zip}

( ) ____________ ( ) ______________ ( ) ______________ _____________________

^{Home Phone Work Phone Cell/Pager Email}

___________________________________________________________________________________

^{Name and Location of Workplace}

____________________________________________ _____________________________

^{2nd Emergency Contact Name Relationship}

_____________________________________________ _________________ ______________

^{Home Address Apt. # City Zip}

( ) ____________ ( ) ______________ ( ) ______________ _____________________

^{Home Phone Work Phone Cell/Pager Email}

__________________________________________________________________________________

^{Name and Location of Workplace}

TRAVEL INFORMATION

Passenger’s School (pick-up location)

___________________________________________ ( ) __________________________

^{Name of School/Center or Program Phone}

_____________________________________________ _________________ ______________

^{Address City Zip}

________________________________________ ____________________________________

^{Name of adult authorized to release child Time child needs to be picked up}

Passenger’s After-School Program (drop-off location)

___________________________________________ ( ) __________________________

^{Name of School/Center or Program Phone}

_____________________________________________ _________________ ______________

^{Address City Zip}

________________________________________ ____________________________________

^{Name of adult authorized to receive child Time child needs to be dropped off}

Days of the week this service is requested:

Monday Tuesday Wednesday Thursday Friday

PARENT’S RELEASE

I hereby authorize OUTREACH to pick up my child at the location listed above as “Passenger’s School”

and drop off my child at the location listed above as “Passenger’s After-School Program.”

_________________________________________________________________________________

^{Parent/Guardian Name (please print)}

_________________________________________________________________________________

^{Parent/Guardian Name Signature Date}

EMERGENCY RELEASE

Please list any pertinent medical information that we should be aware of (allergies, regular medications,

diabetes, conditions, etc.): ___________________________________________________________ ___________________________________________________________________________________

In case of a minor injury, I authorize that first aid may be administered by a qualified person: ___Yes ___No

In case of an accident, I authorize permission to seek emergency medical treatment: ___Yes ___No

In case of an accident, I authorize you to contact our family doctor or dentist: ___Yes ___No

_______________________________________________________ _________________________

^{Family Doctor Telephone}

_______________________________________________________ _________________________

^{Family Dentist Telephone}

_______________________________________________________ _________________________

^{Parent/Guardian Signature Date Relationship to Child}