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Print and fax to (301) 870-6905 attn: Stacy Cage, or mail with check to: HSCC, PO Box 1015, Waldorf, MD 20604
Hard Bargain Farm
Text Box: Humane Education Registration Form Child’s Name_________________________ Nickname (if applicable) _____________________ Age__________________ Date of Birth___/___/___ Phone____________________ Address___________________________________________________________________________________________________________________________________________________________ Gender (optional) __________________ E-mail_______________________________________ Ethnic Background (optional)_____________________________________________________ Mother/Guardian ______________________________________Day Phone_______________________ (Please print first and last name) Evening Phone____________________ Father/Guardian ______________________________________Day Phone_______________________ (Please print fist and last name) Evening Phone_____________________ Person to call if parents(s) cannot be reached (please print clearly): Name__________________________Relationship___________________Phone_____________________ Name__________________________Relationship___________________Phone_____________________ My son/daughter is under the custodial care of: ____both parents _____ mother only ____ father only _____ other Health History Please check any that apply and describe symptoms of allergy and details of illness or health restrictions on additional sheet. ALLERGIES CHRONIC OR RECURRING ILLNESS ___Hay Fever ___Ear Infection ___Drug (specify)__________________________ ___Hear Disease ___ Insect Stings ___Convulsions ___ Asthma ___Diabetes ___Ivy, Oak ___Behavior ___ Food (specify)__________________________ ___Fainting ___Animals (specify)________________________ ___Other (please specify)_________________________________ _________ Date of last Tetanus ________Date of operations of serious injury ________ Date of illnesses or health restrictions Are immunizations up to date? Yes/No If no, please state reasons and provide addition information Medications being taken____________________________________________________________________________________ Health Insurance Company_______________________________________ Policy number ____________________________ Family physician_______________________________________________ Phone number_____________________________ Emergency Authorization: I herby give permission to the Humane Society of Charles County and/or any contact person listed above authorization for treatment for my child in the even I cannot be reached in an emergency. Signature (Parent/Guardian) ___________________________________________ Date__________________________ ` (Please Review and sign the back of this form) T-SHIRT SIZE_______