Hands in Motion 2019 Registration Form
Email address *
Student's Full Name *
Your answer
Student's Home Address *
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
What grade did your child just complete? *
Your answer
Parent/Guardian 1 Name & Relationship *
Your answer
Parent/Guardian 2 Name & Relationship
Your answer
Parent/Guardian 1 Home Telephone # *
Your answer
Parent/Guardian 2 Home Telephone #
Your answer
Parent/Guardian 1 Cell Phone # *
Your answer
Parent/Guardian 2 Cell Phone #
Your answer
Parent/Guardian 1 Employer/Work Phone # *
Your answer
Parent/Guardian 2 Employer/Work Phone #
Your answer
Emergency Contact, Relationship & Phone # *
Your answer
What dates will your child be attending (check all that apply)? *
Required
Immunizations up to date? If not, please explain: *
Your answer
Does your child have allergies? *
Your answer
Does your child have additional needs or special requirements? *
Your answer
Primary Physician's Name, Address & Phone # *
Your answer
Mode of Communication (ASL, Spoken English, Both, Pictures, etc) *
Your answer
Hearing Level & Assistive Listening Device(s) (if applicable) *
Your answer
Consent for Medical Emergency Treatment: The law requires parental permission for medical or surgical treatment of a minor. The hospitals in our area have a similar requirement , relative to admission and treatment. In an emergency, if such treatment becomes necessary, every effort will be made to obtain your consent before treatment. In the event that you are temporarily unavailable, your prior consent to treatment is important to avoid unnecessary delay. However, no surgical procedure will be performed without your knowledge and consent, with the exception of a lifesaving emergency. I understand the considerations set forth above, and hereby consent to and authorize any physician and any hospital involved to perform such emergency medical or surgical treatments as may be deemed necessary for my child. Type your name and date: *
Your answer
Please mark preference in hospital. Parents will assume responsibility for all medical costs *
Required
I authorize SDSD staff to provide my child with transportation to and from field trip outings. *
Required
I hereby authorize SDSD to use any media in which my child may appear. It is understood that the school will only use these materials for educational purposes and releases. *
Required
I understand this release and waiver shall be constructed broadly to provide a release and waiver to the maximum extent permissible under applicable law. Each undersigned here acknowledges this release and its significance. Please type your name and date: *
Your answer
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