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Genius Lab Form

Student Name 学生名字和姓:

First Name

Last Name

Date of Birth 出生日期

YYYY

Student Age and Gender 年龄和性别:

Current School and Grade 学校和年级

Email 电子邮件

Parent/Guardian Name:家长/监护人姓名

First Name

Last Name

Phone 电话号码

(###)

###

####

Address 地址

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do your child have any medical problems that we need to know about? 您的孩子有任何我们需要注意的医疗问题吗?

Do your child have any allergies any food?你的孩子对食物有过敏反应吗?

Are your child on any medications? 你的孩子需要每天服用药物吗:

Do your child have any limits on physical activities? 您的孩子对体育活动有任何限制吗?

Doctor's name 医生姓名:

First Name

Last Name

Doctor's phone number 医生的电话:

(###)

###

####

Emergency Contact Person 紧急联系人

First Name

Last Name

Relationship to the Student 与学生的关系

How did you hear about us? 你是怎么听说我的?

If its a friend please fill out their name

First Name

Last Name

By signing below, I confirm that the information provided on this form is accurate and complete to the best of my knowledge. I understand that this information will be used to ensure the safety and well-being of my child during their stay at Genius Lab.

Parent/Guardian's Signature:

By filling out this session you are agreeing to the statement above

First Name

Last Name

Date

YYYY

I am interested in 我对我孩子的以下内容感兴趣: