STUDENT REGISTRATIONS | Midland.Center

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First Name

Last Name

Birthday

Parent/Guardian Name

Phone

Street Address

City

Region/State/Province

Postal / Zip code

Emergency Contact Name (If Different than Guardian)

Emergency Contact Phone Number (If Different than Guardian)

Allergies/Health Issues

Comments

Preferred Contact Method Required

Text

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By checking this box, the child referenced above has my permission to participate in all activities at The Center. By signing this form I am also giving my child permission to attend off-site trips, as well as activities in the park. I hereby release The Center, and its leaders from any liability in the event of accident or injury to my child. I understand that every effort will be made to contact me in case of an emergency, but in the event that I cannot be reached, I authorize the treatment of this student by qualified medical personnel. By signing, I also consent to allowing my child’s picture to be used by The Center.

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