Registration Form - Little Medical School

Student's Name*

Grade #*

Child's Date of Birth*

Class #

Parent's Name*

Parent's Name

Phone (Day)*

Phone (Evening)

Email*

Cell Phone*

Allergies or Special Medical Conditions

Additional Emergency Contacts

Pediatrician's Name*

Pediatrician's Phone*

Please list the class desired, the day and time, and the amount*

*Additional forms may be required after the selected classes are confirmed. *We will be in touch with you via email to confirm place in class.

Additional Information

Your Name*

First Last

Relation to Child*

Date*

The following people are authorized to pick up my child:

Name

It is responsibility of the Parent/Guardian to notify Little Medical School, in writing, if someone is not legally permitted to pick up your child(ren) from our programs. Prior notification must be given to Little Medical School if someone other than the approved person/s listed above will be picking the child(ren) up after the program.