School Registration Form

Emergency Contact 1
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Emergency Contact 2
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Physician and Medical Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Preferred Hospital
Insurance/Health Coverage (Company)
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.

Previous School
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
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.

Thank you for taking the time to complete this form. I appreciate your interest and commitment to our program! I’ll be in contact with you as soon as possible regarding next steps. Please don’t hesitate to reach out if you have any questions in the meantime.
Should be Empty:

Emergency Contact 1