Registration Form

Registration Form

Student Last Name *
Student First Name *
Grade in school in fall 2011 *
Date of Birth *
Gender (male or female) *
Did the registrant attend CFT last summer? *
Street Address *
City, State, Zip code *
Name of mother/guardian *
Name of father/guardian *
E-mail address for parent/guardian contact *
Home telephone *
Alternate or emergency telephone *
Does the student prefer vegetarian meals? *	Yes No
Does the student have allergies? *	Yes No
List all medications which the student will bring to the school. If no medications will be brought, write NONE. *
Describe any medical conditions that staff should be aware of, including allergies. If no medical conditions, write NONE. *
How will the student travel? Write car, plane, or train. *
Will you register another student from your family? If yes, complete a new registration form.	Yes No
Secondary parent/guardian e-mail address *
Student e-mail address
Do we have permission to post photos of your son or daughter on our website or facebook page? *	Yes No
Do you release and hold harmless the Spiritual Assembly of the Baha'is of Highland Village, TX and the Spiritual Assembly of the Baha'is of Dallas, TX of liability while your child participates in the program?	Yes No
Please provide your child's doctor's name *
Please provide the doctor's phone number
Do the directors of the CFT program and their staff have permission to seek medical treatment and diagnostic testing for your son/daughter in case of an emergency? *	Yes No
If you have health insurance, can you please provide the name of the insurance policy, the group number and subscriber number?