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2017 Gael Scoil Registration
Medical/Emergency Contact/Parental Consent Form
Notre Dame High School
Lawrenceville, NJ

Cost: $100 for the first PAID student; $75 for any other sibling (note, if using a gift certificate that is not counted as the first Paid student)

Student Information

Student's Name
Your answer
Birth Date
mm/dd/yyyy
Your answer
Shirt Size
Home Phone
(xxx) xxx-xxxx
Your answer
Address
Your answer
Parental Consent
Mother/Guardian's Name
Your answer
Phone
(xxx) xxx-xxxx
Your answer
Address
Type SAME if same as student
Your answer
Email Address
Your answer
Work Phone
Your answer
Father/Guardian's Name
Your answer
Phone
(xxx) xxx-xxxx
Your answer
Address
Type SAME if same as student
Your answer
Email Adress
Your answer
Medical
Physician
Name of student's physician to be contacted in an emergency if parent/guardian is unavailable.
Name
Your answer
Day Phone
(xxx) xxx-xxxx
Your answer
Special Medical Problems
Any special medical concerns or dietary information that is important for us to know? For example; Food allergies, other allergies, asthma, seizures, diabetes, ADHD, medications, special conditions? Any special activities in which your child should not participate?
Your answer
Does your child require and special accommodations?
small group setting, one-on-one assistance, physical accommodations, etc.
If yes, please explain
Your answer
If your child is allergic to bee stings, does he/she need
Details
Your answer
Legal
After school my child will be
If picked up, my student will be picked up by
Name of adult authorized to pick up your child. Separate names with commas if more than one.
Your answer
After school my student CAN NOT be picked up
Your answer
Consent - All fields in this section MUST be completed or your registration will not be accepted.
Parent/Guardian electronic signature is required for item below to indicate consent. A physical signature will be collected at registration the first morning of classes.
I consent to allow my child medical care if necessary
Please enter I AGREE on the next line to consent
Your answer
I consent to allow my child minor first aid procedures if necessary
Please enter I AGREE on the next line to consent
Your answer
I have read and understand this form. I agree to indemnify and hold harm-less Notre Dame High School, Gael Scoil, the Ancient Order of Hibernians, their officers, directors, agents and staff.
Please enter I AGREE on the next line to indicate your agreement
Your answer
Your Name
Your answer
Submit
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