Russian School Registration

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Student’s Full Legal Name (first and last) *

Gender *

Female

Male

Birthday *

YYYY

Social Security # *

Student lives with *

Mother

Father

Guardian(s)

Other:

Home Phone *

Address *

Father/Guardian | Employer & Work Phone *

Mother/Guardian | Employer & Work Phone *

If my child is sick, has an emergency, or is suspended and I can not be reached please call and release my child to — Name, Address, Phone #. *

Medical Coverage & Medical ID # *

In the event of an emergency: *

In the event of emergency, when a parent is unavailable, I authorize school personnel to make arrangements for my child to receive medical/hospital care, including necessary transportation in accordance with their best judgment. I authorize the physician named above to undertake such care and treatment as is considered necessary. In the event said physician is unavailable I authorize such care and treatment to be performed by a licensed physician and surgeon. I agree to pay all cost incurred as a result of the foregoing.

I do not choose the above statement and desire the following action in the event of an emergency:

If you chose the 2nd option, what would you want us to do in the event of an emergency?

Other medical problems and/or restrictions *

Parent/Guardian Electronic Signature *

Date *

YYYY

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