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InnerActive Learning Consultants - Enrollment Form
/ 717-576-5268 -
Parent / Guardian Legal Name
Relationship to Child
Is there any additional information or any concerns that you feel we should be aware of to best meet the needs of your child?
Persons designated by parent to whom child may be released
Emergency Contact Information
Emergency Contact Name / Relationship
Emergency Contact Number
Physician Contact Number
Name of Insurance Provider
State law requires that we have written authorization from a child's legal guardian to seek medical help in the event of a medical emergency. Selecting the box below will provide us with that authorization. Our policy, in the event of a medical emergency is to contact you first. If we can not reach you, we will try to contact any others you may designate. In the event that we are unable to contact you or your designated representative(s), or if the medical emergency warrants immediate response, we will act on behalf and in the best interest of the child.
I DO grant medical authorization on behalf of my child.
I DO NOT grant medical authorization on behalf of my child.
Photo / Image Release
InnerActive Learning Consultants, LLC may wish to use pictures/images of your child participating in our service. By selecting the Image Release, you are granting permission for your child's image to be used in relation to InnerActive's promotional items, website, social media information, and other service related material.
I DO grant image release permission
I DO NOT grant image release permission
A copy of your responses will be emailed to the address you provided.
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