2017-18 MCC-Kids Registration Form
(Please complete a separate form for each child)
Child's First Name
Your answer
Child's Last Name
Your answer
Date of Birth
Your answer
School
Your answer
Grade
Your answer
Known Allergies
Your answer
Medications that we should be aware of
Your answer
Any special conditions or other information you would like us to know about your child
Your answer
Home Street Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Guardian #1 Full Name
Your answer
Guardian #1 Relationship to child
Your answer
Guardian #1 Primary Phone
Your answer
Type
example: home, cell, work
Your answer
Guardian #1 Secondary Phone
Your answer
Type
example: home, cell, work
Your answer
Guardian #1 Email address
Your answer
Guardian #2 Full Name
Your answer
Guardian #2 Relationship to child
Your answer
Guardian #2 Primary Phone
Your answer
Type
example: home, cell, work
Your answer
Guardian #2 Secondary Phone
Your answer
Type
example: home, cell, work
Your answer
Guardian #2 Email address
Your answer
Emergency contact #1 (other than parents/guardians)
include full name, relationship, and contact info.
Your answer
Emergency contact #2 (other than parents/guardians)
include full name, relationship, and contact info.
Your answer
Physician
Name, Location & Phone # (Physician and Insurance information is optional. We would only use this information in an unlikely event where we would need to seek emergency medical attention for your child. This information will not be used in any other way.)
Your answer
Health Care Insurance Provider & Policy #
Your answer
Submit
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