Registration Form

Emergency Contact 1
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship To The Student
Sign Out
Emergency Contact 2
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship To The Student
Sign Out
Physician and Medical Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Preferred Hospital
Insurance Information
Primary Insurance Carrier
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.

Photo/Video Release Form

Throughout the year the LOL STEAM CENTER and other various organizations may visit and take pictures, video, and/or audio recordings of your child. These recordings may be used in your child’s classroom, for group projects, published materials, written articles, etc. In order to allow your child to fully participate in these activities we require your signed consent. We understand that parents may have specific beliefs that may conflict with this request. Signature Below
I agree to allow my child to be audio recorded, videotaped, or photographed. I authorize the release of audio recordings, videotapes, or photographs for public viewing on local channels, for public showing, or for publication at the discretion of LOL STEAM CENTER
Signature
Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.

$10.00

Total

Credit Card

Apple Pay

Cash App Pay

Insurance Information