NORTHWESTERN - Registration Form
Student Information
Student First Name *
Your answer
Student Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Address *
Your answer
City *
GRADE *
T-SHIRT SIZE *
Parent/Legal Guardian Information
Can pick up child and are preferred emergency contact
Parent First and Last Name *
Your answer
Relation to child *
Your answer
Phone Number *
Your answer
Emergency Contact
Allowed to pick up child
Contact First and Last Name *
Your answer
Relationship to Child *
Your answer
Phone Number *
Your answer
My child can NOT be released to the following individual(s):
Your answer
Check all that apply to your child
Medical Concerns, Allergies, Medications, Dietary or Other Special Needs
Your answer
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