Please Tell Us About Your Child


Student’s Name:______________________

Home Address:_________________________

City, State, Zip:_________________________

Age:____ Birthdate:___________ M or F

School:____________________

Grade:_________

Mom’s Name:____________________________

Mom’s Phone:____________________________

Dad’s Name:_____________________________

Dad’s Phone:_____________________________

Guardian’s Name:_________________________

Guardian’s Phone:_________________________

Emergency Contact:________________________

Emergency Phone:_________________________

Email Address:____________________________

 

Please tell us about any existing medical problems:

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How did you find out about us?
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