JUNE17212013BOOTCAMPREGISTRATIONFORM

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Parent/GuardianInformation

Mother/GuardianFirstName:

RegistrationDate:

M.I.

LastName:

M.I.

LastName:

M.I.

LastName:

Address:
HomePhone:()
OfficePhone:()
CellPhone:()
Email:

Father/GuardianFirstName:
Address:
HomePhone:()
OfficePhone:()
CellPhone:()
Email:

ChildInformation
1stChildFirstName:
Namechildpreferstobecalled:

Grade/Class:

ChildsAddress:
Gender:[]Male[]FemaleDateofBirth:
Listanyexistingmedicalconditions,medicationand/orspecialattentionyourchildmayrequire?

Allergies:
PediatriciansName:

2ndChildFirstName:
Namechildpreferstobecalled:

Phone:()

M.I.

LastName:
Grade/Class:

ChildsAddress:
Gender:[]Male[]FemaleDateofBirth:
Listanyexistingmedicalconditions,medicationand/orspecialattentionyourchildmayrequire?

Allergies:
PediatriciansName:

Phone:()

JUNE17212013BOOTCAMPREGISTRATIONFORM

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EmergencyContacts&AuthorizedPickupPersons:
1stContact/PickUpName:___________________________________________Phone:
_________________
RelationshiptotheChild:__________________________
2ndContact/PickUpName:__________________________________________Phone:
_________________
RelationshiptotheChild:__________________________
3rdContact/PickUpName:__________________________________________Phone:_________________

RelationshiptotheChild:__________________________
4thContact/PickUpName:___________________________________________Phone:
_________________
RelationshiptotheChild:__________________________

AdditionalComments&Information:
Isthereisanyotherinformationthatthatwouldbehelpfultoourmanagementandteachingstaff?
_________________________________________________________________________________________
____
_________________________________________________________________________________________
____

Signature:
ParentsSignature:

Date:

ThankYou!