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After Care - Special Program Registration Form 2017 - 2018
2017-2018 School Year (Program is run under the auspices of the After Care Program.)
Email address
Program Registering For:
Name:
Your answer
Class:
Address:
Your answer
Home Phone:
Your answer
Cell Phone:
Your answer
Email Address
Your answer
Additional Contact 1:
Your answer
Additional Contact 2:
Your answer
What would you like the instructor/ staff to do in the event of an emergency?
Your answer
Does your child have an allergy?
Required
If yes, please indicate allergies.
Your answer
Does your child's allergy require an Epi Pen to be administered?
Required
Will you be supplying After Care/ Zumba/Edible Art with an EpiPen?(separate from the one provided for the normal school day)
Required
Are there any specific medical conditions or issues of concern?
Required
If yes, please explain briefly.
Your answer
The following people are given permission to pick up my child/children from the Zumba/Edible Art/Drama:
Your answer
The following people are not permitted to pick up my child/children from Zumba/Edible Art/Drama:
Your answer
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