KSSB Boys Weekend - March 31- April 2 2017
Registration Form
Date
MM
/
DD
/
YYYY
Name of Student Attending
Your answer
Birthdate
MM
/
DD
/
YYYY
School District Name
Your answer
Student'sTeacher of the Visually Impaired
Your answer
Parent Name
Your answer
Home Address
Your answer
Phone
Your answer
Email
Your answer
Vision Diagnosis
Your answer
Visual Acuity (if known)
Your answer
Name of person we may contact in an emergency
Your answer
Family Doctor
Your answer
Family Doctor Phone #
Your answer
Allergies (drug,food, etc)
Your answer
Medication/Amount and Time Given
Your answer
Reason for medications
Your answer
Name of Health Insurance Company
Your answer
Name of Policy Holder
Your answer
Group #
Your answer
Individual #
Your answer
Medical Card (SRS) # (If Applicable)
Your answer
Parent Signature/ Type name here for signature
Your answer
Submit
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