STUDENT INFORMATION: 

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Email:  

Name:

   Age: SSN:

Address:

Home Phone:  

              Cell:

 Other Phone:

Ethnicity/Race: Select One Black White Hispanic Indian Other

PARENT INFORMATION:

Mother Name:  Employer:  

Work Phone:     Cellular Phone:  

Father Name:   Employer:

Work Phone:     Cellular Phone:   

Authorized Person(s) for Pick -Up

(1)  

(2)   

(3)

Medical Information

Physician:      Phone:

 Dentist:           Phone:

Preferred Hospital:    Phone:

List Allergies to food or materials below: