Family Registration Form Page 2
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4F
R
F
AMILY
EGISTRATION
ORM
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SHEET
OF
Child Information
st
1
Child First Name:
M.I.
Last Name:
Name child prefers to be called:
Grade/Class:
Child’s Address:
Gender: [ ] Male [ ] Female Date of Birth:
Child’s S.S. #:
List any existing medical conditions, medication and/or special attention your child may require?
Allergies:
Pediatrician’s Name:
Phone: (
)
Address:
Photographs: May we maintain a photo of your child for security purposes? [ ] Yes [ ] No
2nd Child First Name:
M.I.
Last Name:
Name child prefers to be called:
Grade/Class:
Child’s Address:
Gender: [ ] Male [ ] Female Date of Birth:
Child’s S.S. #:
List any existing medical conditions, medication and/or special attention your child may require?
Allergies:
Pediatrician’s Name:
Phone: (
)
Address:
Photographs: May we take and maintain a photo of your child for security purposes? [ ] Yes [ ] No
3rd Child First Name:
M.I.
Last Name:
Name child prefers to be called:
Grade/Class:
Child’s Address:
Gender: [ ] Male [ ] Female Date of Birth:
Child’s S.S. #:
List any existing medical conditions, medication and/or special attention your child may require?
Allergies:
Pediatrician’s Name:
Phone: (
)
Address:
Photographs: May we take and maintain a photo of your child for security purposes? [ ] Yes [ ] No
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