Small Town Times 2-10 - Page 19

SUMMER SCHOOL REGISTRATION June 12 —July 21, 2017 Please register by June 1, 2017 Student’s Name Parent’s Name Address Phone Please circle your response to the following: Grade Child was in during the 2016—2017 school year. Pre-K K 1 2 3 4 5 6 Emergency Contact Information: Name: Relationship Phone: Doctor: Address: Town My child may be released to the following individuals: My child MAY NOT be released to the following individuals: Please list any special instructions or helpful information about your child: (For example: food allergi