BETY Jr 2017-2018 Registration Form
Please make sure you have your medical insurance information readily available
Participant's First Name
Your answer
Participant's Last Name
Your answer
Participant's Grade During the 2017-2018 School year
Participants Date of Birth
MM
/
DD
/
YYYY
Participant's Email
Your answer
Participant's Cell Phone (xxx) xxx-xxxx
Your answer
Street Address
Your answer
Apartment #
Your answer
Town/City
Your answer
Zip Code
Your answer
Parent/Guardian 1 Name
Your answer
Parent/Guardian 1 Email
Your answer
Parent/Guardian 1 Phone Number
Your answer
Parent/Guardian 2 Name
Your answer
Parent/Guardian 2 Email
Your answer
Parent/Guardian 2 Phone Number
Your answer
Participant lives primarily with:
Participant Medical Concerns (Allergies, Food Restrictions, anything you feel is necessary to know)
Your answer
Medical Insurance Plan Provider
Medical Insurance Provider Address
Your answer
Medical Insurance Provider Phone # (xxx) xxx-xxxx
Your answer
Medical Insurance Group #
Your answer
Medical Insurance Policy #
Your answer
Participant's Primary Care Provider's Name
Your answer
Primary Care Provider's Phone # (xxx) xxx-xxxx
Your answer
Emergency Contact Name 1 (Other than Parents/Guardians)
Your answer
Emergency Contact 1 Relation to Participant
Your answer
Emergency Contact 1 Phone # (xxx) xxx-xxxx
Your answer
Emergency Contact Name 2 (Other than Parents/Guardians)
Your answer
Emergency Contact 2 Relationship to Participant
Your answer
Emergency Contact 2 Phone # (xxx) xxx-xxxx
Your answer
Thank you for registering for BETY Jr 2017-2018!
Be sure to join us on BAND to receive our calendar of events and all communications!

BETY Jr: http://band.us/n/afaaU1r8X5icn

BETY Parents: http://band.us/n/abafU6r7X4hab

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