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"SUAH School of African Music & Dance" (SSAMD) Registration Form - (2021-2022 Season)
Section 1
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Email
*
Your email
Student Information:
Student's Name:
*
Your answer
Student's Pronouns:
He/Him/His
She/Her/Hers
Them/They
Address, City, State, & Zip:
*
Your answer
Students Date of Birth:
*
MM
/
DD
/
YYYY
Age of Student:
*
Your answer
School and Grade Level:
*
Your answer
Work Phone #:
Your answer
Home Phone #:
Your answer
Cell Phone #:
Your answer
Are you new to SSAMD?:
*
Yes
No
Medical
Physician:
Your answer
Hospital Preference:
Your answer
Allergies:
Your answer
Health Insurance Provider and Policy No.:
Your answer
Are there any mental or physical disabilities / special needs we should know about?
Your answer
Additional Health Info. / Comments:
Your answer
Parent(s) / Guardian(s) Info. (18 yrs. old and younger)
Parent Name (#1):
Your answer
Relationship to Child:
Mother
Father
Grandparent
Guardian
Other
Cell Phone #:
Your answer
Work Phone #:
Your answer
Authorized to Pick Up Child?:
Yes
No
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Parent Name (#2):
Your answer
Relationship to Child:
Mother
Father
Grandparent
Guardian
Other
Cell Phone #:
Your answer
Work Phone #:
Your answer
Authorized to Pick Up Child?:
Yes
No
Clear selection
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.
Your answer
Emergency Information
Emergency Contact Person Name:
Your answer
Emergency Contact Phone Number:
Your answer
Emergency Contact Relation to Student:
Grandparent
Aunt/Uncle
Other Family Memeber
Family Friend
Other
Clear selection
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