(Please Enter Parent/Guardian Name)
(Please Enter Student's Name)
What grade is your child entering?
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
(Date)
/
Month
/
Day
Year
Date
(Signature of parent or person having legal custody or legal guardian)
Address
City
State
Zip
(Telephone
Minor's Birth Date:
/
Month
/
Day
Year
Date
Date of Minor's Last Tetanus Shot
/
Month
/
Day
Year
Date
Minor's Allergies
Medicine Minor is Taking
Minor's Medical History
Email of parent/guardian signing form:
example@example.com
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