Summer Program 2015

BELOW IS A SAMPLE OF WHAT IS PROVIDED IN THE PDF AND ZIP FILE LOCATED ON THE RIGHT. PLEASE DOWNLOAD THE ACTUAL FORMS AND COMPLETE. CONTACT BOWDOIN BOUND WITH ANY QUESTIONS ABOUT OUR STUDENT RESOURCES. THANKS.

Please attach one copy of a recent photo of the student to this form.

Bowdoin Bound, Inc., 2015 Summer Program

Participant’s Name ____________________
Date of Birth ______________ Age _______________
Grade for the 2015-16 School Year____________________
Name of the Participant’s School for the 2015-16 School Year ____________________
Participant’s Email Address ____________________
Parent/Guardian’s Name ____________________
Parent/Guardian’s Home Telephone Number ____________________
Parent/Guardian’s Work Telephone Number ____________________
Parent/Guardian’s Cell Phone Number ____________________
Parent/Guardian’s Email Address ____________________
Parent/Guardian’s Name ____________________
Parent/Guardian’s Home Phone Number ____________________
Parent/Guardian’s Work Phone Number ____________________
Parent/Guardian’s Cell Phone Number ____________________
Parent/Guardian’s Email Address ____________________

In an emergency if we cannot each a parent/guardian, whom should we call?

Emergency Contact’s Name ____________________
Emergency Contact’s Address ____________________
Emergency Contact’s Home Telephone Number ____________________
Emergency Contact’s Work Telephone Number ____________________
Emergency Contact’s Cell Phone Number ____________________
Emergency Contact’s Email Address ____________________
Emergency Contact’s Relationship to the Participant ____________________
Participant’s Doctor’s Name ____________________
Participant’s Doctor’s Telephone Number ____________________
Participant’s Dentist’s Name ____________________
Participant’s Dentist’s Telephone Number ____________________
Name of Participant’s Insurance Provider ____________________
Insurance Policy Holder’s Name ____________________
Participant’s Relationship to the Policy Holder ____________________
Insurance Policy Number ____________________
Insurance Policy Group Number (if applicable) ____________________
Is the participant taking any prescription medication? ____________________
If yes, please list the medication and strength ____________________

Please lists the Participant’s medical issues and allergies

____________________
____________________
____________________

Parent/Guardian Signature ____________________
Date ____________________

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