Madison Lanes After School Bowling Signup

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Basic Information

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School
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{# pageNumbers}

Emergency Care Information

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If emergency treatment is required, may the authorities use their own judgement in sending the child to the hospital or doctor most easily accessible before the parents are reached?
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If my child becomes ill, he/she may be released to the following person(s)

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{# pageNumbers}

Medications

Prescribed Medication {binding ItemNumber}

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Madison Lanes After School Bowling Signup

Madison Lanes After School Bowling Signup

Basic Information

Student's Name
{binding displayValue}
Parent's Name
{binding displayValue}
School
{binding displayValue}
{ binding firstError.message }

Emergency Care Information

Home Address
{binding displayValue}
Phone
{binding displayValue}
First Person Notified
{binding displayValue}
Phone
{binding displayValue}
Second Person Notified
{binding displayValue}
Phone
{binding displayValue}
Father's Business Address
{binding displayValue}
Phone
{binding displayValue}
Mother's Address
{binding displayValue}
Phone
{binding displayValue}
Choice of Local Doctor
{binding displayValue}
Phone
{binding displayValue}
Address
{binding displayValue}
Choice of Local Dentist
{binding displayValue}
Phone
{binding displayValue}
Address
{binding displayValue}
If emergency treatment is required, may the authorities use their own judgement in sending the child to the hospital or doctor most easily accessible before the parents are reached?
{binding displayValue}
Preferred Hospital
{binding displayValue}
Does your child have any medical or emotional problems that require care while he/she is in school? IF so, please explain:

If my child becomes ill, he/she may be released to the following person(s)

Name
{binding displayValue}
Phone
{binding displayValue}
Name
{binding displayValue}
Phone
{binding displayValue}
{ binding firstError.message }

Medications

Prescribed Medication {binding ItemNumber}

Medication
{binding displayValue}
Dosage
{binding displayValue}
Schedule
{binding displayValue}
Usage
{binding displayValue}
Side Effects
{binding displayValue}
{ binding firstError.message }
Discontinued Medications(s) and Date
Allergies