Registration Form
Child’s Name:___________________________________________________ Date of Birth:___________________________ Grade:______ Age: _______
Parent/Guardian Name: _____________________________________________________________ Address: ______________________________________________________________ Phone: __________________________ Cell: _________________________ Email:__________________________________________________________
I am registering for (circle): Feb 27
th
March 5
th
March 6
th
HEALTH HISTORY OF CHILD:
This is kept confidential.
Attach additional sheet if necessary
Please list any allergies: ______________________________________________________________ Describe your child’s allergic reaction: ______________________________________________________________ Other medical concerns: ______________________________________________________________ Medications being used: ______________________________________________________________
Please note that The LongTale Publishing Staff cannot dispense any medications. Do not send any medicationsto class with your child.
Does your child wear: glasses( ) contact lenses( ) hearing aid( )corrective shoes( ) prosthesis( )?Any other info concerning your child’s health that we should be aware of: _____________________________________________________________
Emergency Contact Information:
Name:_____________________________ Relationship:__________________ Phone:_________________________________________________________ In the event that neither I nor my designee can not be contacted at the time of amedical emergency, I consent to emergency treatment determined necessary by aqualified physician.Preferred Medical Facility __________________________________(optional)
Add a Comment