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Playgroup Registration Form for Additional Children 2017-2018

ADDITIONAL CHILD


Parent/Guardian Name:_________________________________________

Child’s Information:

Child’s Name:___________________________________________________ Date of Birth:_______________     

Gender:   M  /  F                Insured:     Y / N                  Immunized:   Y /  N       

 Primary Language:______________________________________________

Low birth weight?  Y  /   N        Premature?  Y /   N     B-3 Services   Y  / N                         

 Child’s Race: __American Indian or Alaska Native   __Asian     _Black or African American     __Pacific Islander        __White

 Child’s Ethnicity:     __Hispanic or Latino         __Not Hispanic or Latino

 Restrictions: Food / Allergies / Health / Other: __________________________

 

I give the FRC permission to use, at its discretion, any photos or videos taken while in programs. Yes   No

 I hereby relieve the East Hartford Board of Education of liability resulting from personal injuries arising from participation in this program.

 ____________________________               ____________________                (Signature)                                                      (Date)       

Office Use Only 

PAT Family ______     B-3______        Playgroup Day__________               

Immunizations Received_______        ASQ Completed___                                     


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