Loras for Literacy Reading Clinic

February 12 - May 16, 2013

Child's Full Name (First, Middle Initial, Last): Address: City / State / Zip: Home Phone: Gender: Select One Female Male Date of Birth: Current Grade: School: Classroom teacher: Parent Information Mother's Name: Father's Name: Parent Primary Email Address: Best number to reach parent while child is attending the reading clinic: Alternative number to reach parent while child is attending the reading clinic: Emergency Contact Name: Emergency Contact Phone Number: Insurance & Physician Information I understand the Loras for Literacy Reading Clinic does not provide health insurance and is not responsible for any medical costs incurred due to illness or accidental injury.: Child's Physician: Physician's Address and Phone: Please list any medical conditions we should be aware of (including allergies of any type): Please list Child's Insurance Company Name and Policy Number: Media Release Parent/Guardian: I authorize and understand photos/video may be taken of my child while enrolled in the program and may be utilized publicly for marketing, advertising or other similar communication.: ____________________________________________________________________________________ Digital Signature By filling in the following digital signature (full name+last 2 digits of SS#), you confirm the information above is accurate and true.: