Class Registering For

Student Type

Name

First Name

Last Name

School

Sex

Age

Subject

Grade as of 9/18

Date of Birth

Paren/Guardian Name

Phone

District of Residency

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Information

In case an emergency, we will first try the phone number listed on the top of the registration form (parent/guardian). Please list 3 additional contacts if needed: Name and Phone Number of Emergency Contacts (please list 3)

Family Physician

First Name

Last Name

Family Physician Phone

(###)

###

####

Dentist

First Name

Last Name

Dentist Phone Number

(###)

###

####

Will your child be carrying a prescribed epi-pen?

Yes

Asthma

Yes

ADD/ADHD

Yes

LD (Learning Disability)

Yes

Diabetes

Yes

Seizures

Yes

Headaches/Migraines

Yes

Serious Illness/Injury

Yes

Contact Lenses

Yes

Any other conditions that may require special care, medication or diet? Any other concerns?

MEDICAL AUTHORIZATION I hereby authorize, consent and direct Foundry 42, its directors, officers, and employees, and any physician, hospital, or other health care provider selected by Foundry 42 to take such action as is necessary in the circumstances to provide emergency care and related treatment to my above--named child in my absence, should the need arise while he/she is participating in the programs of Foundry 42 and release them from any liability, either personal or as a professional in carrying out that action. I hereby designate Foundry 42, its directors, officers, and employees as my authorized agent for the signing of any consent forms required by any such health care provider in connection with such health care. MEDICAL INSURANCE COMPANY:

Policy Holder's Name

Insurance Company Policy Number

Signature of Parent/Guardian

Date

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Student Registration Form

STUDENT REGISTRATION FORM

SPRING SEMESTER CLASSES:

WINTER SEMESTER CLASSES:

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Foundry42+

Student Registration Form

STUDENT REGISTRATION FORM

SPRING SEMESTER CLASSES:

WINTER SEMESTER CLASSES: