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Sing in Somerville Camp

Student Name/Apellido *
Student Name/Apellido
Student Address/Direccíon *
Student Address/Direccíon
Phone Number/Números de teléfono *
Phone Number/Números de teléfono
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone Number *
Emergency Contact Phone Number
Birthdate/Fecha de nacimiento *
Birthdate/Fecha de nacimiento
I Am Interested In A Full Day Option *
I Am Interested In A Scholarship For My Child *
Is Your Child On An IEP or 504 Plan? *
Is Your Child Currently Taking Medication? *
Please note that NO medication will be distributed by the employees or director of Sing In Somerville. Please make sure that you attend to this and all other health matters before your child attends the program each morning.
Does Your Child Have Any Allergies? *
Snacks will be provided during our program. Please indicate if your child has any food allergies.
Primary Care Physician *
Primary Care Physician
Phone Number *
Phone Number
Emergency Contact *
Emergency Contact
Phone Number *
Phone Number
I authorize Sing in Somerville to take, use, and publish photographs, sound recordings, and/or video for publicity purposes.