Space Camp Registration Form

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Registration Form
Children Information
Indicate the Program To Be Register
First Name
Second Name
Last Name
Gender
School Name
Grade
Birth Date
Age
Child's Home Phone
Address
Parent/Guardian - Contact Information
Parent/Guardian 1 - Cédulayour full name
First Name
Last Name
Home Phone
Work Phone
Cell Phone
Address
Parent/Guardian 2 - Cédulayour full name
First Name
Last Name
Street Address
Home Phone
Work Phone
Cell Phone
Child lives with:
Person responsible for payment
Emergency Contact
First Name
Last Name
Home Phone
Work Phone
Cell Phone
Relation to child:
Medical Release Information
Insurance Policy Number
Name of Health Insurance Provider
Primary Physician
Phone
Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).more details
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Is your child allergic to any type of food or medication?pick one!
Explain
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Does your child require a special diet?pick one!
Explain
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Does your child require a special attention?pick one!
Explain
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I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.

International Insurance (Optional)
Preferred registration date
NASA Space Camp Astronaut Suit (Optional)
Specify:
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Additional Commentsmore details
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