I would like my child ___________________________________ to attend The Smile Center.
My child’s birthday is __________________________________
Current Age ________
Parent(s)/Guardian(s):
Name: __________________________________________
Relation: ________________________________
Name: __________________________________________
Relation: ________________________________
Address: __________________________________________________________ __________________________________________________________
__________________________________________________________
Phone: _________________________________
Emergency Contact: ______________________________________________
Relation: ___________________________________
Phone: _____________________________________
Family Physician: __________________________________________________
Phone:_______________________________________
Allergies (animals, food, medicine, outdoor, etc.):
___________________________________________________________
___________________________________________________________
___________________________________________________________
Specific Likes/Dislikes of Child:
___________________________________________________________
___________________________________________________________
___________________________________________________________
Child’s Name (Print): _________________________________
Parent/Guardian Name (Print): _________________________________________
Signature: ____________________________________
Date: ____ /____ / 20____
The Smile Center has a website and pictures are regularly posted as well as activities that make the local newspapers. Please grant your permission for these photos to be posted and/or published.
Child’s Name: ________________________________________
Parent/Guardian Signature: _______________________________________
Date: ____ / ____ / 20 ____
My child’s birthday is __________________________________
Current Age ________
Parent(s)/Guardian(s):
Name: __________________________________________
Relation: ________________________________
Name: __________________________________________
Relation: ________________________________
Address: __________________________________________________________ __________________________________________________________
__________________________________________________________
Phone: _________________________________
Emergency Contact: ______________________________________________
Relation: ___________________________________
Phone: _____________________________________
Family Physician: __________________________________________________
Phone:_______________________________________
Allergies (animals, food, medicine, outdoor, etc.):
___________________________________________________________
___________________________________________________________
___________________________________________________________
Specific Likes/Dislikes of Child:
___________________________________________________________
___________________________________________________________
___________________________________________________________
Child’s Name (Print): _________________________________
Parent/Guardian Name (Print): _________________________________________
Signature: ____________________________________
Date: ____ /____ / 20____
The Smile Center has a website and pictures are regularly posted as well as activities that make the local newspapers. Please grant your permission for these photos to be posted and/or published.
Child’s Name: ________________________________________
Parent/Guardian Signature: _______________________________________
Date: ____ / ____ / 20 ____