Name of Student *

First Name

Last Name

Boy/Girl *

Girl

Boy

Phone Number *

(###)

###

####

Parent's Name

First Name

Last Name

I give permission for my child to be photographed with the RT class for promotional purposes. (brochures, newsletter, flyers)

I agree

I disagree

Emergency Notification *

First Name

Last Name

Emergency Number *

(###)

###

####

Alternate Phone *

(###)

###

####

Are there any health issues which might impact your child while in our care? *

Yes

No

Date *

MM

DD

YYYY