Welcome Form

SENSORY TAEKWON-DO

WELCOME FORM

Student Name*

Sex

Male

Female

DOB*

Month

Day

Year

Address, City, State & Zip*

Phone*

Cell Phone #

Parent/Guardian*

Relationship*

Emergency Contact*

Emergency #*

Does your child have an Aide?

Yes

No

Aide's Name

Aide's Phone #

Aide's Email

How long have they worked with your child?

Where did you hear about us?

Website/Online Search

Friend/Family

Saw The Banner Our Front

Who can we thank for the referral?

I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used to help determine the appropriate treatment program. If there is any change in my child’s medical status, I will inform the staff.

Child's Name*

Parent/Guardian Signature*

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