Parent/Guardian(s) Cell Phone Number (Please specify which parent) *
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Emergency Contact Name and Number *
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Student Cell Phone Number
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Allergies (Write N/A if none) *
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List Any Special Needs, Medications, and/or Medical Concerns for Child (Write N/A if none) *
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Does Your Child Need Transportation? *
Berlin Christian Church Has Permission to Transport Child *
Please List Other People Who Have Permission to Transport and Check-Out Child
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Has Student Been Immersed?
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Berlin Christian Church Has Permission to Photograph Child *
This Form Was Filled Out For (choose all that may apply) *
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By entering your name in the box below, you are indicating that you are 18 years or older, and that all the information on this form is true and accurate, to the best of your knowledge. *
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