Child's Name *

 
Child's Age *

 
Grade Level of Child *

 
Parent/Guardians Name(s) *

 
Parent/Guardians Home Phone

 
Parent/Guardians Cell Phone

 
Diagnosis (if applicable)

 
Allergies or Intolerances

 
Dietary Restrictions

 
Physical Restrictions

(is there any physical activity that has been recommended that your child avoid?)
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