Penn Family Resource Center

Family Resource Center Parental Release & Consent

Student/Post-Doc Information

First Name*
Last Name*
Email*
School*
Graduation Date*
Degree Type*
Field of Study*

If you selected "Other", please specify your field below.

Penn Status*

Student/Post-Doc Contact Information

Local Address (include city + zip):*

Home Phone:*

Work Phone:

Cell phone:

Emergency Contact Information

If you are not available, this is who we should contact in case of emergency.

Name:*

Relation to Participant:*

Email:*

Cell Phone:*

Employer:

Employer's Address:

Work Phone:

Work Schedule:

Home phone:

Information about your Child(ren)

How many kids do you have:

Please tell us the names of other adults who will watch your children at the Family Center.

Medical Insurance for your Child(ren)

Insurance Company:*

Insurance Company Address (include city + zip):*

Insurance Company Phone Number:*

Policy Number:*

Name of employer or group name, if any:

Name of insured, employee or participant:*

Does your insurance require you to contact the insurer or primary care physician or other person to approve medical treatment to assure insurance coverage for the medical bills?* Yes No

Other info that may be helpful in helping your claim against your insurance company for any medical bills your child/ward incurs:

Playroom Hours

The Family Center will close for the summer on May 14. A playroom and lacation space will open in the Grad Center on June 25.

Family Resource Center

Suite 240, Houston Hall
3417 Spruce Street
University of Pennsylvania
Philadelphia PA 19104
215-746-2701
kids@gsc.upenn.edu

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