Girls and Boys Weekend March 23-25, 2018
This is the registration for the Spring 2018 Girls and Boys Weekend event at Kansas State School for the Blind.
Date *
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Name of Participant *
Your answer
Birthdate *
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Participant Grade (current) *
Your answer
School District Name *
Your answer
Participant Vision Diagnosis *
Your answer
Participant Visual Acuities (if known)
Your answer
Participant Teacher of Students with a Visual Impairment (TVI) *
Your answer
Participant Parent/Guardian Name *
Your answer
Participant Home Address (include city and zip code) *
Your answer
Phone (including area code) *
Your answer
Parent E-mail *
Your answer
Emergency Contact 1 (Name and phone #) *
Your answer
Emergency Contact 2 (Name and phone #)
Your answer
Family Doctor *
Your answer
Family Doctor Phone # *
Your answer
Allergies (drug,food, etc) *
Your answer
Medication/Amount and Time Given *
Your answer
Reason for medications *
Your answer
Name of Health Insurance Company *
Your answer
Name of Policy Holder *
Your answer
Group # *
Your answer
Individual # *
Your answer
Medical Card (SRS) # (If Applicable)
Your answer
Parent Signature/ Type name here for signature *
Your answer
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