PROGRAM REGISTRATION FORM

Name                    

Home phone       

Mobile phone        

Email                     

Address                 

Name                    

Date of birth         

School grade        

Gender                 

Allergies                

Special interests     

Special needs         

Parents' names       

Mobile phone         

Doctor's name / number

Emergency contact name / number

Name                    

Date of birth         

School grade        

Gender                        

Allergies                

Special interests     

Special needs         

Parents' names       

Mobile phone         

Doctor's name / number

Emergency contact name / number

Permission to seek treatment
I give permission, in case of a medical emergency, to take my child to a hospital for treatment, to include evaluation of injuries, x-rays and needed care.

yes                  no

Permission to use photographs of my child in Sheldrake publicity
I give permission to use photographs of my child for publicity, website and newsletters.

yes                  no