6th Annual Children of The Lotus Retreat
Registration Form
Parent/Guardian's Name ( First/Last) *
Your answer
Addreess *
Your answer
City
Your answer
State *
Your answer
Zip *
Your answer
Email Address *
Your answer
Best Phone Number *
Your answer
Please complete registration for each child
#1-Child's First/ Last Name *
Your answer
Age *
Your answer
Ethnicity *
Gender *
Medical Data:
Please list any current medications, allergies, food allergies, or chronic health concerns
Your answer
#2-Child's First/ Last Name
Your answer
Age
Your answer
Ethnicity
Gender
Medical Data:
Please list any current medications, allergies, food allergies, or chronic health concerns
Your answer
#3- Child's First/ Last Name
Your answer
Age
Your answer
Ethnicity
Gender
Medical Data:
Please list any current medications, allergies, food allergies, or chronic health concerns
Your answer
#4-Child's First/ Last Name
Your answer
Age
Your answer
Ethnicity
Gender
Medical Data:
Please list any current medications, allergies, food allergies, or chronic health concerns
Your answer
#5-Child's First/ Last Name
Your answer
Age
Your answer
Ethnicity
Gender
Medical Data:
Please list any current medications, allergies, food allergies, or chronic health concerns
Your answer
Emergency Contact
Emergency Contact First/Last Name *
Your answer
Emergency Contact Phone Number *
Your answer
To register additional children please complete and submit a new form.
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