Summer Program 2015

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

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Parent/Guardian Signature ____________________
Date ____________________