2019 Annual Meeting Childcare/Activity Program Registration

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* 1. Parent/Guardian Information:

Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Email Address:

Phone Number: *

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* 2. Do you have a cell phone? If so, please list cell phone number (In the event of an emergency, we will call you. Please have your cell phone on at all times):

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* 3. Child's Name:

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* 4. Child's Date of Birth (Example: 01/01/2009):

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* 5. Child's Age:

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* 6. Does this child have a bleeding disorder?

Yes

No

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* 7. What type of bleeding disorder? (if applicable)

Hemophilia A

Hemophilia B

VWD

Other

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* 8. Does this child have any allergies? If yes, please list...

No

Yes

Allergies:

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* 9. Does this child have any special needs? If yes, please list...

No

Yes

Please Specify: