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Student Information
Full Name:
Age:
Street Address:
City:
State:
Zip Code:
Home Phone:
Mobile Phone:
E-Mail Address:
Will the student need school provided transportation from the address listed above:
Shirt Sizes:
Extra Small
Small
Medium
Large
X-Large
2X-Large
3X-Large
Family Information
Parent's/Guardian's Full Name::
Relation to Student:
Street Address:
City:
State:
Zip Code:
Cell Phone:
E-Mail Address:
Emergency Contact
In case of an emergency please contact:
Phone Number:
Relation to Student:
If for any reason I/we cannot be reached, please contact the following person(s) whom I/we hereby authorize to seek emergency medical or surgical care for my/ourchild:
Phone Number:
Relation to Student:
Dietary and Medical Information
Does the student you are registering have any medicial issues we should be aware of:
If yes, please explain:
Does the student have any speical diet needs:
If yes, does the student have a disability that requires a special diet:
If yes, describe the major life activities affected by the disability:
If no, list the medical condition that requires special nutrition or feeding needs.:
Vegetarian, Food Allergy, Other