Name of Student *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name (Mother / Parent 1) *

First Name

Last Name

Cell Phone *

(###)

###

####

Name (Father / Parent 2) *

First Name

Last Name

Cell Phone *

(###)

###

####

In Case of Emergency

If above student is ill or an emergency situation occurs and student must be taken home, I give the permission to the following individuals to be called and have the student released to them (OTHER THAN PARENTS).

First Name

Last Name

Phone *

(###)

###

####

ALLERGIES *

If yes please describe

YES

NO

I give permission to have my child taken to the hospital in case of emergency

Yes

No