WGES Make-A-Difference Club Registration Form

Please print. Please complete one form per child. Registration grants your child permission to attend the monthly meetings. Be sure to sign this form.

Student Information:

Last name: ______________________ First name: __________________

Grade: _______ Teacher’s Name: __________________________

Parent or Guardian Information:

Last name: ______________________ First name: _____________________

Relationship: _______________ Email Address: ___________________ Home Phone: _______________ Work or Cell Phone: ___________________

Emergency Contact Information:

Name: _________________________ Relationship: _____________________

Phone number: _______________________

Medical Information:

Allergies: _______________________________

Medical Problems: _________________________

Medication: ______________________________

All medical information is confidential and will only be shared with medical professionals in the event of a medical emergency. If your child has serious or complicated medical issues, please arrange to have a responsible adult attend meetings with him/her.

Transportation: These people have permission to pick my child up after meetings.

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______________________________________________________________Parent/Guardian Signature:_________________________________________