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Muraco BOKS registration form 2018-2019
* Required
Participant last name
*
Your answer
Parent/ guardian primary contact email
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Grade
*
Choose
K
1
2
3
4
5
Participant first name
*
Your answer
Teacher (last name)
*
Your answer
Parent/ Guardian primary contact name
*
Your answer
Parent/ guardian primary contact number
*
Your answer
Additional contact name
*
Your answer
Relationship to child
*
Your answer
Additional contact number
*
Your answer
Medical Information- My child requires the use of:
*
Note: Nurse is not on duty during BOKS. Although lead trainers have CPR training, they are not trained to use an Epipen. If child has epipen or inhaler, either child must be able to administer himself, or parent/caregiver must be present during class.
Epipen
Inhaler
None
If child needs Epipen or inhaler, can he/she administer himself/ herself?
*
Yes
No
Not applicable
Required
Doctor Name
*
Your answer
Doctor Phone
*
Your answer
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