Thoughtful Thursdays Enrichment Cooperative (TTEC)    REGISTRATION FORM
               
Parent's Names:

_________________________________         _________________________

Last name                                            First names                                                                                                 

                                                                                                          write the Classes your children are in below:
                                                                                                                     11:30        12:30        1:30        2:30
Child(ren)’s Names and ages: ________________________________      _______      _______         ______       ______ 

                                           ________________________________      _______      _______         ______      ______  
 
                                           ________________________________      _______      _______        ______       ______  
 
                                          ________________________________      _______      _______         ______       ______  

                                          ________________________________      _______     _______         ______       ______  



Work Phone:_________________ Home Phone:_________________ Cell Phone:________________

E-mail address: ______________________________________

Number where you can most likely be reached during TTEC class time: ______________________

Name and phone number of someone else to call in case of an emergency:
_________________________________        _________________

_________________________________        _________________

Any special medical needs or issues: ______________________________________________________

__________________________________________________________________________________

Doctor Name and phone: __________________________    ______________________________

I, ___________________(parent name) hereby give permission for any and all medical attention to be administered to my child(ren) ___________________________________________________________
(name(s) of child(ren)) in the even of accident, injury, sickness, etc., until such time as I may be contacted. I also assume the responsibility for the payment of any such treatment. This release is effective for Thoughtful Thursdays Enrichment Cooperative from 09/08/11 through 05/10/12.
I UNDERSTAND AND AGREE TO ABIDE BY THE GUIDELINES FOR COOPERATION.

______________________________________            ___________________________
(Parents Signature)                            (Date)

Facility Fee:  Amount Paid____________       Date Paid____________    Check #/Cash:_________