Boys Weekend - October 27th - 29th 2017
Registration Form
Date *
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Name of Student Attending *
Your answer
Birthdate *
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School District Name *
Your answer
Student'sTeacher of the Visually Impaired *
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Parent Name *
Your answer
Home Address *
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Phone *
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Email *
Your answer
Vision Diagnosis *
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Visual Acuity (if known)
Your answer
Name of person we may contact in an emergency *
Your answer
Family Doctor *
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Family Doctor Phone # *
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Allergies (drug,food, etc) *
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Medication/Amount and Time Given *
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Reason for medications *
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Name of Health Insurance Company *
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Name of Policy Holder *
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Group # *
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Individual # *
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Medical Card (SRS) # (If Applicable)
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Parent Signature/ Type name here for signature *
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