2016 Great Improvement Academic Services Registration Form
Child's Name__________________________________________ M/F (Circle) Address____________________________________________________________ City____________________________________ State_______ Zip__________ Home Phone#________________________________________________________ E-mail and/or Facebook Address_____________________________________________________ Age____ Date of Birth________ Grade completed as of June 2011_____ Parents'/Guardians' Name(s)__________________________________________ Other numbers where parents/guardians may be reached (work, cell, etc.) ___________________________________________________________________ ___________________________________________________________________
ALTERNATIVE CONTACT - for emergency and you cannot be contacted:
Name/Relationship__________________________________________________ Phone Number(s)____________________________________________________MEDICAL INFORMATION
Dates of last immunizations: (please provide a copy also) MMR___________ DPT___________ Polio__________ Chicken Pox__________ Tetanus_______ Hep B_________ HIB____________ Allergies:_________________________________________________________ ___________________________________________________________________ ___________________________________________________________________MEDICATIONS List below, with doses and times
(Please write "none" if child does not take any medication.) ___________________________________________________________________ ___________________________________________________________________MEDICAL CONDITIONS (including ADHD)
(Please write "none" if no medical conditions exist.) ___________________________________________________________________ Physician name and number__________________________________________ Insurance name and policy__________________________________________
By signing this registration form I grant Great Improvement Academic Services/Calvin Lowry the right to photo-graph and use my child(s) image for promotional use.
(Downloadable Registration Print Application)$65.00 non-refundable registration fee.
