姓氏: 出生日期: (例子: 01/12/1986) 姓別: . Male Female 學校名稱: . ABCDEFG School XYZ School Other 年級: PK K 01 02 03 04 05 06 07 08 09 10 11 12 醫師: 電話: (例子: 713-888-8888) 特別醫療: 過敏:
城市: 洲: 區碼:
住家: (例子: 713-888-8888)
傳真: 父親日間電話:
父親手機号碼: 母親日間電話: 母親手機号碼: 緊急聯絡: (不是父母)
電話: (例子: 713-888-8888)
Class Information
本地夏令營
國內夏令營為國際學生
Days of Pick-Up
MonTueWedThurFriSat
Time of Pick-Up:
. Newspaper Direct Mail Yellow Pages Word of Mouth Internet Other
I, the undersigned, as the legal guardian of the student above hereby granting authority to the staff of Fame Well School to render a judgment concerning medical assistance in the event of an emergency/accident in my absence. I agree not to hold FWEC or its employees responsible in any way while any accident occurs during transporting my child. Yes I agree statement above
