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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_______