2017-18 Round Up Registration Form
Email address *
Child(ren): Please list *
Your answer
Home Address *
Your answer
Mother's Name *
Your answer
Mother - Work phone *
Your answer
Mother - Cell phone *
Your answer
Father's Name *
Your answer
Father - Work phone *
Your answer
Father - Cell phone *
Your answer
Name of Emergency Contact *
Your answer
Number of Emergency Contact *
Your answer
Please list all known allergies and medical conditions *
Your answer
Health Insurance *
Students who are not covered under their parents’ insurance plan should obtain school insurance. According to the Standard Life and Casualty Insurance Company, your child is covered while attending after school programs. Please list insurance provider and policy number.
Your answer
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