APPLESEED ACADEMY REGISTRATION FORM

 

Please print this page to complete this form.

Either have it brought along with your child to his or her first meeting

or mail to:  Appleseed Academy, 116 West Glen Ave., Syracuse, NY 13205

 

There is no cost for Appleseed Academy.  All students currently in grades 9 -12 are invited.

 

 

 

My child _______________________________________________ has my permission to attend this youth event.

 

 

In case of emergency please call:

 

1.  _________________________________________________ Telephone __________________________

 

 

     _________________________________________________ Telephone __________________________

 

 

My child has the following allergies and medical conditions that are important for you to know about:

 

 

1.  ____________________________________________________________________________________

 

 

2.  ____________________________________________________________________________________

 

 

3.  ____________________________________________________________________________________

 

 

Pictures and video may be taken of the children participating in this event.  Photos  may be used for crafts, programming, church publicity, publications and website.  Your signature is your permission.  As we are not able to guarantee anonymity, please do not  register children who may not be photographed.

 

 

Parent/Guardian: ___________________________________________________________________________

 

 

Address:  _________________________________________________________________________________

 

 

Phone: ______________________________________________________

 

 

 

Signature: _____________________________________________________  Date: ______________________