Child's Name   First Name M. Last Name First Name / Last Name

Date of Birth   mm/dd/yyyy

Gender   Male Female

Grade   Pre-K Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade

Parent's/Guardian's Name   First Name M. Last Name First Name / Last Name

Daytime Phone    -  -  (XXX)-XXX-XXXX

Evening Phone    -  -  (XXX)-XXX-XXXX

Address   Address 1 Address 2 AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY City State Zip Code

Email Address

Parent's/Guardian's Name   First Name M. Last Name First Name / Last Name

Daytime Phone    -  -  (XXX)-XXX-XXXX

Evening Phone    -  -  (XXX)-XXX-XXXX

Address   Address 1 Address 2 AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY City State Zip Code

Email Address

Alternative Emergency Contacts

Primary Emergency Contact   First Name M. Last Name

Daytime Phone    -  -  (XXX)-XXX-XXXX

Relationship

Evening Phone    -  -  (XXX)-XXX-XXXX

Address   Address 1 Address 2 AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY City State Zip Code

Secondary Emergency Contact   First Name M. Last Name First Name / Last Name

Relationship

Daytime Phone    -  -  (XXX)-XXX-XXXX

Evening Phone    -  -  (XXX)-XXX-XXXX

Address   Address 1 Address 2 AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY City State Zip Code

Medical Information

Hospital/Clinic Preference

Physician's Name

Phone Number    -  -  (XXX)-XXX-XXXX

Insurance Company

* Policy Holder   First Name M. Last Name First Name / Last Name

Policy Number

Allergies/Special Health Considerations

Text Authorizing   Yes No

Text Number    -  -  (XXX)-XXX-XXXX

Parent's/Guardian's Signature

Date