Pine Bush Central School District: 2019 Middle School Summer School Program Registration
General Information
*
Your answer
Student School *
Parent/Guardian Name *
Your answer
Mailing Address *
Your answer
Street Address (if different from mailing address) *
Your answer
Parent/Guardian e-mail *
Your answer
Phone Numbers
List preference of phone contact.
Primary phone number (indicate home, work, mobile) *
Your answer
Secondary phone number (indicate home, work, mobile) *
Your answer
Alternative phone number (indicate home, work, mobile)
Your answer
Emergency Contacts and Medical Information
*People who will be called in an emergency and have permission to pick up your child.
Contact #1 *
Indicate relationship to child and phone number
Your answer
Contact #2 *
Indicate relationship to child and phone number
Your answer
Contact #3
Indicate relationship to child and phone number
Your answer
Please list/describe any allergies, medical alerts, medicines: *
Your answer
Doctor's name and contact information *
Your answer
*All medication given during the day must be brought to the summer school administrator by a parent or guardian by 12:00 pm on Thursday, June 27th!
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