Teahe Club Registration Application

Gender*
Age:*
Name:*
Nickname:
Address:*
State*
Mothers Name: *
Fathers Name: *
Grade:*
Birthday:*
Home Phone:*
S.S.N.*
List All known Allergies:*
List All Current MEDICATIONS:*
School Name:*
Teacher Name:*
School Address:*
Parent Premission to Check Childs Progress:*
Is Child Eligible for State/Federal Aid?*
Emergency Contact Name:*
Relationship:*
Daytime Phone #:*
Emergency Contact name 2:*
Relationship:*
Daytime Phone #:*
Child's Physician:*
Is Child under physician Care Now?*
If Yes! Give Details *
Physician Address:*
Physician Phone # :*
Has this child been Hospitalized?*
Date:*
Reason( if within Last 2 Years)*
Date of last Visit/Examination:*
Signature of Parent or Guardian:*
Date:*
ZIP CODE*


 
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The National Foundation of Enrichment for the Arts, Humanities, & Education, Inc.