*
Diet Chemistry

KIDS WORKSHOP REGISTRATION

PERSONAL INFORMATION

Child's Name:

School Name:

Age:

DOB:

Gender:

Grade:

Parent/Guardian(s):

Address:

Parents Email:

Phone:

MEDICAL INFORMATION

Please list any dietary restrictions or food allergies.

Does your child have any other allergies (medicine, environmental, etc.)

Does your child have any physical, mental or emotional conditions that we should know about (ADD or ADHD, diabetes, asthma, etc.)? Please list any issues that may affect your child's safety or ability participate in cooking class.

Please list any medications your child is currently taking.

EMERGENCY CONTACT INFORMATION

Emergency Contact Name

Relationship

Phone Number

Alternate Phone Number

List the people other than those listed above who are authorized to pick up your child.
Name
Phone
DL#