North Rampart Community Center Registration Form

Select which program you're enrolling your child in:
Student's Name
Date of Birth
School Attending
Parent's Name
Home Address
Telephone Number
Emergency Contact
Relationship
Address
Telephone Number
Physical Impairment(s)
Specifics Regarding Impairment(s)
Transportation Consent
Picked Up By:
Swimming permissions
Does your child have any specific medical conditions that we should be aware of that my prohibit your child from participating in activities?
Specific Medical Information
Do we have permission to take your child to the nearest hospital for medical treatment?
	Photographs of my child may be used for program purposes.
	My child has permission to participate in field trips.

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