PARENT'S APPROVAL, STUDENT, FAMILY & PARTICIPATION WAIVER

LAST NAME *

FIRST NAME *

EMAIL ADDRESS *

STUDENTS NAME *

STUDENTS BIRTHDAY *

MM

/

DD

/

YYYY

I/we hereby advise that the above named minor(s) has the following allergies, medicine reactions or unusualphysical conditions, which should be made known to a treating physician: (If none, please write the word“none”. If yes, put first name of child and the allergy/condition.): *

Do you have any more students that attend LRES? *

Yes

No