DUGSI  Registration Form
Taubah Center
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PARENT'S INFORMATION
Please, provide the parent/legal guardian's current information
Parent Full Name (First, Middle, Last) *
Parent's Phone *
Secondary Phone
Parent's E-mail *
Home Address (Street, City, State, Zip) *
County *
Student's Full Name (First, Middle, Last) *
Date of Birth *
MM
/
DD
/
YYYY
Grate Level *
Current / Most Recent School Name *
MEDICAL INFORMATION
Please, provide any medical information that may be useful in case of an emergency.
Any known allergies? *
.
Yes
No
Please, list all know allergies, if any!
Family Phisician's Name
Phisician's Phone
Name of 1st Emergency Contact *
Phone of 1st Emergency Contact *
Name of 2nd Emergency Contact
Phone of 2nd Emergency Contact
WARNING!                                                                                                                                                                      Under Georgia law, there is no liability for an injury or death of an individual entering these premises if such injury or death results from the inherent risks of contracting COVID-19.  You are assuming this risk by entering these premises.                                                   Any person entering the premises waives all civil liability against this premises owner and operator for any injuries caused by the inherent risk associated with contracting COVID-19 at public gatherings, except for gross negligence, willful and wanton misconduct, reckless infliction of harm, or intentional infliction of harm, by the individual or entity of the premises. *
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