Radiate 2021

Child's Information
Name
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Sex
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Age
Grade for 2020/2021 School Year
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Address
T-shirt size
Family Information
Parent/Guardian Name #1
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Phone --
Phone --
E-mail
Parent/Guardian Name #2
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Phone --
Phone --
E-mail
Alternate Pickup
Name
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Phone --
HEALTH INFORMATION
ALL INFORMATION WILL BE HELD IN STRICT CONFIDENCE
I hereby warrant to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. Of the following statements pertaining to medical matters, sign only those in accordance with your wishes:
Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor.
In the event of an emergency and you are unable to reach me, contact:
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Relationship
Phone --
Family Doctor
Phone --
Medications My child will bring all such medications, well labeled, that are necessary. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency are as follows:
Medication(s), Dosage(s), and Administration:
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*
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My son/daughter has had an episode of the following:
Allergic reactions to the following (foods, dyes, latex, etc.)
Payment Information
Tuition  
Selection Extended

First Child | $20.00

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Order Summary
Subtotal
Discount
Sales Tax
Shipping & Handling
Total

Payment Type
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