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Annual Registration Form
Last Name
First Name
Middle Name
Birth Date
Most current membership renewal date
Last Name
First Name
Relationship to Child
Address
City
Postal Code
Home Phone
Work Phone
Employer
Name
Relationship to Child
Home Phone
Work Phone
Your child will only be released to an authorized person listed on this form (parent/guardian and/or emergency contact). In case of an emergency or an unforeseen circumstance, please indicate the name, address and phone number of any other person/s who you authorize to pick up your child on your behalf. A parent/guardian's written authorization for pickup must be received in person by parents/guardian before your child will be released to anyone not listed here. If not received, and we cannot notify you by phone, the child will not be released.
Name
Address
Phone
Relationship to member
Name
Address
Phone
Relationship to member
Name
Address
Phone
Relationship to member
Name
Address
Phone
Relationship to member
Name
Address
Phone
Relationship to member
Name
Address
Phone
Relationship to member
Name
Address
Phone
Relationship to member
Doctor
Office Phone
Address
City
Postal Code
Medical Ins. #
Child's Personal ID#
Allergies
Medical Problems
Medications
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