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Muraco BOKS registration form 2018-2019
Participant last name *
Parent/ guardian primary contact email *
Date of Birth *
MM
/
DD
/
YYYY
Grade *
Participant first name *
Teacher (last name) *
Parent/ Guardian primary contact name *
Parent/ guardian primary contact number *
Additional contact name *
Relationship to child *
Additional contact number *
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.
If child needs Epipen or inhaler, can he/she administer himself/ herself? *
Required
Doctor Name *
Doctor Phone *
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