S.I.S.T.A. Enrollment Form

Name

Email Address

Child's Name

Parent/Guardian(s) Name

Child's Last Name

Address

Alternate Number

School

Grade

Emergency Contact #1

Emergency Contact #2

What, if applicable, are your child’s medical, health, or special conditions?

Medical Coverage: Health Insurance Information, Provider, and Number

S.I.S.T.A., Inc. has permission to:

Obtain Emergency Medical Care in the Event of an Emergency
Leave the Premises for Scheduled Trips
Discuss abstinence/safe sex practices
Have photos taken for program related media & press releases

Child’s Method of Arrival & Departure:

Walk Alone
Walk w/Sibling
SEPTA
Drop-off/Pickup by Parent/Guardian/Emergency Contact

Verification

S.I.S.T.A. Enrollment Form

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