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CES KID'S CLUB 2021-2022
Registration Form
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* Indicates required question
Student First and Last Name
*
Your answer
Grade for School Year 2021-22
*
Your answer
Teacher
*
Your answer
Parent First and Last Name
*
Your answer
Parent Phone Number
*
Your answer
1st Emergency Contact : First and Last Name and Phone Number
*
Your answer
2nd Emergency Contact: First and Last Name and Phone Number
*
Your answer
The following persons can pick up your child with proper ID: (PLEASE ENTER FIRST AND LAST NAME)
*
Your answer
I work for Horry County Schools:
*
Yes
No
E-Mail Address:
*
Your answer
Medical Information
Student Date of Birth
*
MM
/
DD
/
YYYY
Physician's Name
*
Your answer
Physician's Phone Number
*
Your answer
Hospital Preference
*
Your answer
Health Insurance Company
*
Your answer
Will this child need medication regularly? (If yes, you will need to complete a medication form at a later date)
*
Yes
No
Any medical conditions staff should be aware of?
*
Yes
No
If you answered Yes to the previous question, please explain
Your answer
Please list any activity or dietary restrictions
*
Your answer
Incoming Child Development/Kindergarten Student
*
Yes
No
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