Student's Name *

First Name

Last Name

Gender

Male

Female

Which days will student attend program?

Monday

Tuesday

Wednesday

Thursday

Friday

Parent or Guardian Name *

First Name

Last Name

Emergency Contact 1

First Name

Last Name

Emergency Contact 1 Primary Phone Number

(###)

###

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Emergency Contact 1 Secondary Phone Number

(###)

###

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Emergency Contact 2

First Name

Last Name

Emergency Contact 2 Primary Phone Number

(###)

###

####

Emergency Contact 2 Secondary Phone Number

(###)

###

####

Is there anyone else who is authorized to pick up your child from the program?

First Name

Last Name

Authorized Pick Up Contact Phone Number

(###)

###

####

Doctor's Name

First Name

Last Name

Dentist's Name

First Name

Last Name

Dentist's Phone Number

(###)

###

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