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Part 2 of 2-Additional Information

Student

First Name

Last Name

Emergency Contact #1

First Name

Last Name

Phone (Emergency Contact #1)

(###)

###

####

Emergency Contact #2

First Name

Last Name

Phone (Emergency Contact #2)

(###)

###

####

Health Insurance Company

Health Insurance Policy Number

Health Insurance Phone Number

(###)

###

####

Primary Care Doctor

Phone (Primary Care Doctor )

(###)

###

####

Allergies

If none known, enter "None"

Medical Conditions

Please list any known diagnosed medical conditions.

Will your child need any medications or treatments administered after shool?

If so, please indicate treatment or mediation, dose, and instruction.

Notes

Is there anything else we should know about your child?

After completing registration, please proceed to Online Payment to submit your deposit.