2016-2017 EYC Participant Information
Participant Full Name: *
Your answer
Preferred Name (if different)
Your answer
Date of Birth *
MM
/
DD
/
YYYY
2016-2017 Grade in School *
Participant medical information: Allergies, chronic illness, disabilities, etc
Your answer
Physical, medical or dietary restrictions (Please note we are not equipped to provide for major dietary restrictions. Participants must be capable of managing necessary dietary adjustments.)
Your answer
Last Tetanus Immunization/Booster (must be up-to-date) *
MM
/
DD
/
YYYY
Other pertinent medical history and/or information:
Your answer
May over-the-counter medication be given to your child by an adult sponsor? *
Do you have another child to register for EYC? *
Next
Never submit passwords through Google Forms.
This form was created inside of George Fox University. Report Abuse - Terms of Service