Student Registration Form

Student Registration

Parent/Guardian Information

Parent/Guardian name *

Parent phone *

Parent email *

Emergency contact name

Emergency contact phone

Student Information

Name of school or group *

First Name *

Last Name *

Student email

Student phone

Gender

Female

Male

Does Student Require Epi-Pen?

Yes

Briefly describe allergy *

Does student have any medical issue or prescribed medications to be aware of?

Yes

Briefly describe medications or medical issues. *

Photography release

Yes

You authorize School Time Travel to obtain, store and/or use, without payment any photographs, slides and/or video/digital recordings of your child for public relations, marketing/advertising, and/or internal training purposes.