Panoply Arts After-School Program
Please complete one form per child.
Please Select One: *
Required
Child's Full Name *
Your answer
Age *
Your answer
Address *
Your answer
Primary Parent Contact Information *
Please include the name, email, and phone number(s) of the primary parent or guardian.
Your answer
Secondary Parent Contact Information
If available, please include the name, email, and phone number(s) of another parent or guardian.
Your answer
Emergency Contact Information *
Please include the name, email, and phone number(s) of an emergency contact.
Your answer
Please List Allergies, Medications, Pertinent Medical History, or other concerns. *
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Insurance *
Your answer
Hospital Preference *
Please list any special instructions you want carried out in case of an emergency.
Your answer
I, the parent and/or guardian, give my permission to Hearthstone to take my child to the hospital in an emergency situation in the event that I cannot be reached by telephone. *
Please provide an electronic signature.
Your answer
Photo Release
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