"SUAH School of African Music & Dance" (SSAMD) Registration Form - (2021-2022 Season)
Section 1
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Email *
Student Information:
Student's Name: *
Student's Pronouns:
Address, City, State, & Zip: *
Students Date of Birth: *
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/
DD
/
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Age of Student: *
School and Grade Level: *
Work Phone #:
Home Phone #:
Cell Phone #:
Are you new to SSAMD?: *
Medical
Physician:
Hospital Preference:
Allergies:
Health Insurance Provider and Policy No.:
Are there any mental or physical disabilities / special needs we should know about?
Additional Health Info. / Comments:
Parent(s) / Guardian(s) Info. (18 yrs. old and younger)
Parent Name (#1):
Relationship to Child:
Cell Phone #:
Work Phone #:
Authorized to Pick Up Child?:
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Parent Name (#2):
Relationship to Child:
Cell Phone #:
Work Phone #:
Authorized to Pick Up Child?:
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Is there anyone else other than the parents/guardians listed above that is authorized to pick up your child? If YES, please list their NAME, RELATIONSHIP TO CHILD, and PHONE # below.
Emergency Information
Emergency Contact Person Name:
Emergency Contact Phone Number:
Emergency Contact Relation to Student:
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