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REGISTRATION FORM

 

To print the form and mail it, Click here!

Please provide the following contact information:

First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
Mother's Name
Father's Name

Please provide Emergency Contact Information if parents cannot be reached::           

Name of responsible adult to contact

Phone

Please provide Childs Medical Contact Information::       

Physician Names
Physician Phone#
Physician Address
Physician State
Physician Zip Code

Divine Dimensions has my permission to call the above named Physician in case of an emergency when as a parent I cannot first be reached

Yes  No

Please provide additional information that would be helpful (ex. allergies, etc.):

           

 

Please identify and describe Child:

First Name
Grade
Date of Birth
Please provide name and grade of other children attending Divine Dimensions.

 

First Name
Grade
Date of Birth
First Name
Grade
Date of Birth

 

 

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