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Please use a separate form for each student enrolling Please make checks payable to RECA CHINESE SCHOOL Name of student: ____________________________________Age: ______ Birthdate: ____________ Address: ______________________________________ City___________________ Zip __________ Telephone: ___________________________ Alternate phone ______________________________ E-Mail Address: _____________________________________________________________________ Parent’s or guardian’s name (if under 18): ____________________________________________ CLASS PLACEMENT
WAIVER OF LIABILITY In consideration of the acceptance of my application for the REDWOOD EMPIRE CHINESE ASSOCIATION Chinese School, I do hereby for myself, my heirs, executors and administrators, waive, release and forever discharge any and all rights and claims for damages which I may have or which may hereafter accrue to me against the RECA Chinese School or their responsible officers, directors, agents, representatives, successors, and/or assigns for any and all damages which may be sustained and suffered by me in connection with my said or arising out of my traveling to, participating in and returning from said activities.Signature: _______________________________________ Required for adult students (over 18) Parent or guardian signature: ___________________________________ Required for students under age 18 |
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EMERGENCY INSTRUCTIONS Alternate name to call in emergency: ________________________________ Relationship: _______________ Address: ____________________________________________________ Phone: ___________________ Does this student have any physical ailments (such as diabetes, allergies, asthma, etc.) or does this student take medication during class time? _________ If yes, describe: _____________________________________ _____________________________________________________________________________________________ Date of last tetanus immunization: ______________________ MEDICAL TREATMENT AUTHORIZATION Should the need arise, I, hereby, give permission to RECA to obtain the services of a physician to provide prompt emergency medical treatment for (student) ___________________________________________ . Doctor: _____________________________________________________ Phone: _____________________________________________________ Medical insurance carrier: _________________________________________________________________ Medical insurance number: _________________________________________________________________ Other instructions: _______________________________________________________________________ Parent/guardian signature: _________________________________________________________________ Required for children under 18 5/10/2003: JHC for RECA For dates and tution, please ask for current class information sheet. |