TEEN TUESDAY REGISTRATION

Gender

Male

Female

Name *

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent's Phone Number *

(###)

###

####

Pick-up Person *

First Name

Last Name

Pick-up Person's Phone Number *

(###)

###

####

If we can not reach you in an emergency do we have permission to seek medical attention for your child?

Yes

No

Medical Information

Please check all boxes that apply

Allergies

Dietary Restrictions

Taking Medications

Physical Information

Please check all boxes that apply

Student has physical limitations

Student has pre-existing health issues

Date *

MM

DD

YYYY

Can the student leave on their own?

Yes

No