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414 Grant Street | Sewickley, PA | 15143 | 412.741.4550
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KIDS DIGITAL REGISTRATION FORM: FIVE
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Child Name
*
First
Last
Birthdate
*
Grade
*
Nursery (birth-2 years old)
Preschool (3-4 years old)
Pre-K (4 years or older by Sept. 1-going into Kindergarten the next school year.)
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
School
Does your child carry an EPI pen?
Yes
No
Medical History
ADD/ADHD
Asthma
Autism
Cardiac Problems
Diabetes
Wears glasses
Other
If "other," please describe, also list allergies/dietary restrictions:
MEDICAL RELEASE: In the event of accident, injury, or illness, I authorize any and all medical attention necessary to be administered to my child, listed above, under the direction of such medical professionals as the Church determines appropriate under the circumstances. Please print your signature below:
*
WAIVER: By sending my child to Sewickley Presbyterian Church (SPC) events, I agree to indemnify and hold harmless Sewickley Presbyterian Church, its staff, volunteers, or anyone affiliated with SPC, from any liability for an accident or injury which may be incurred. Please print your signature below:
*
Todays' Date:
*
Submit
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