Sage Programs Registration Form

Child's Medical & Emergency Information
Health Practitioner Name

First NameLast Name
Health Practitioner Phone

Area CodePhone Number
Past injuries, chronic illness, other...
Taking the following regular medications (allopathic or herbal or other)
Allergies (including food)
Any behavioral issues we should know about
Any other information you feel would be helpful for us to know in case of an emergency.
Medical Treatment Release Form
I hereby give my permission that my child may be given emergency treatment by a qualified staff member of Sage Programs. I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment.

In the event that I cannot be contacted, I further consent to the medical, surgical, and hospital care, treatment, and procedures to be performed for my child by a licensed physician or hospital to safeguard my child’s health.
Child's Name

First NameLast Name
Parent's Name

First NameLast Name
Parent's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Name

First NameLast Name
Parent Name #1

First NameLast Name
Parent Name #2

First NameLast Name
Parent Signature #1
Parent Signature #2
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Photo Release
I give permission for Sage Programs to use photos of my child and our family for purposes of non-commercial illustration, fundraising, and Sage Programs website viewing.
Child Name

First NameLast Name
Parent Name

First NameLast Name
Parent Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Registration & Contact