Saturday Enrichment Program 2018
Student Name *
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Grade
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Street Address
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City
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State
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Zip Code
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Phone Number
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Parent's Cell Phone Number
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Parent's E-Mail Address *
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Student's E-Mail Address
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School where student is currently enrolled
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Town
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Session I Choice *
Session II Choice *
Is your daughter in good health?
Do you assume all responsibility for the health of your child?
Of the statements pertaining to medical matters, check next to those in accordance with your wishes:
Emergency contact name *
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Emergency contact relationship *
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Emergency contact phone number *
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Family doctor name
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Family doctor phone number
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If your child takes a medication, please list the name, dosage, and administration instructions below:
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My daughter has had an episode with the following or has been diagnosed with:
Allergic reactions to the following (foods, latex, etc.):
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Has had a medical surgery within the last six months?
Under doctor's care?
Has a medically prescribed diet?
Cardiac condition?
Physical limitations
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Immunizations are current and up to date?
You should also be aware of these special medical conditions of my child:
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Insurance carrier
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Name of Insured
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Insurance policy number
Your answer
I do not carry medical insurance at this time
By typing your full name in this space, you medically consent to the information previously listed on this form. *
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PERMISSION SLIP FOR PARTICIPATION
Parent and student acknowledge and are aware that even with proper supervision, use of protective equipment and strict observance of rules, there are risks inherent in participation in the Saturday Enrichment Program. Parent and student hereby release, hold harmless, indemnify and discharge Mother Seton Regional High School, its employees, agents and volunteers from all liability for damages, loss or injury to persons or property arising out of or in connection with student?s participation in the above described activity that may be filed by, on behalf of, or for the above named student. For purposes of this agreement, liability means all claims, demands, losses, causes of action, suits or judgments of any and every kind that arises from student?s participation in the Saturday Enrichment Program. Parent and student further expressly agree that the foregoing release and waiver provisions are intended to be as broad and inclusive as is permitted by the law and that if any portion of it is held void, voidable, or unenforceable, the remaining portions shall remain in full force and effect. The undersigned has read and voluntarily signs this release and waiver of liability and further agree that no oral representations, statements or inducements, apart from this agreement, have been made.
I AGREE and acknowledge my permission for my daughter to participate in the Saturday Enrichment Program *
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