Please complete this 2017-18 Program Registration and Cosent Form for your child(ren).
Name of Child(ren)

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* 1. Name of Child(ren)

School Grade (Fall of 2017)

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* 2. School Grade (Fall of 2017)

Birthday and Age

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* 3. Birthday and Age

Street Address, City, State, Zip

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* 4. Street Address, City, State, Zip

Parent(s)/Guardian(s) Name and Email Address

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* 5. Parent(s)/Guardian(s) Name and Email Address

Parent(s)/Guardian(s) Home and Cell Phone

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* 6. Parent(s)/Guardian(s) Home and Cell Phone

Emergency Contact Name and Contact Number

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* 7. Emergency Contact Name and Contact Number

Name and Relationship of Adults Approved to Pick-Up your Child(ren)

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* 8. Name and Relationship of Adults Approved to Pick-Up your Child(ren)

Ministry Participation at Salem (check all programs you're interested in)

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* 9. Ministry Participation at Salem (check all programs you're interested in)

Medical or Behavioral Concerns (including allergies)

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* 10. Medical or Behavioral Concerns (including allergies)

Current Medications

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* 11. Current Medications

Parent/Guardian Consent (check all that apply)

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* 12. Parent/Guardian Consent (check all that apply)

Parent/Guardian Electronic Signature

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* 13. Parent/Guardian Electronic Signature

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