Child's Name
*
First Name
Middle Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Child's Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name 1
*
First Name
Last Name
Parent/Guardian 1 Address (if different from child)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Parent/Guardian Name 2
First Name
Last Name
Parent/Guardian 2 Address (if different from child)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Insurance Provider
Policy Number
Group Number
Preferred Hospital
Type a question
Current Medical Conditions
Current Medication
Allergies
Special Accommodations
Emergency Contact
Relationship to Student
Emergency Contact Phone
Alternate Emergency Contact
Alternate Emegency Contact Phone
Emergency Treatment and Transportation Authorization
*
Parent/Guardian Signature
Off Premises Activities Authorization
*
Parent/Guardian Signature
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