2010 여름학교 Application Download
Student Information
Full Name:___________________ Date of Birth: _________
Gender: [ ] Male [ ] Female T-Shirt Size: [ ] XS [ ] S [ ] M [ ] L
Grade applying for: [ ] K [ ] 1st [ ] 2nd [ ] 3rd [ ] 4th [ ] 5th
List any existing medical conditions, medication and/or special attention your child may require?
Allergies:
Address: _______________________________________________________________
City: _______________________ State: _______ Zip:___________________________
Parent /Guardian 1
Full Name: _________________ Relationship to Student: _________
Address (if different): __________________________________________________
Home Phone: _____________ Cell Phone: _________________
Work Phone: _____________ E-Mail:_______________________
Parent /Guardian 2
Full Name: _________________ Relationship to Student: _________
Address (if different): ________________________________________________
Home Phone:______________ Cell Phone:_________________
Work Phone:______________ E-Mail:______________________
Emergency Contact
Full Name: ___________________ Relationship to Student: _______
Address: ___________________________Cell Phone: ____________
[ ] Authorized to pick up your child
Emergency Contact
Full Name: ________________ Relationship to Student: _______
Address: __________________Cell Phone: __________________
[ ] Authorized to pick up your child
Authorization for Emergency Medical Attention:
In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:
Name of Physician: ____________________________ Phone: ___________________
Address: ____________________________________________________________________
Name of Emergency Medical Care Facility: ________________________________________________
Address: _________________________________________ Phone: _______________
I give consent for the facility to secure any and all necessary emergency medical care for my child.
Signature
– Parent or Legal Guardian______________________ Date: ______________
[ ] I have read and agree to follow the procedures.
I hereby [ ] give [ ] do not give consent for my child to be transported and supervised
by the summer school staff.
I hereby [ ] give [ ] do not give my consent for my child to participate in Field Trips.
I hereby [ ] give [ ] do not give my consent for my child to participate in Water Activities.
Signature
– Parent or Legal Guardian________________________________Date: _____________
