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115 Mt Pleasant Road, Newtown CT 06470

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Home School Online Registration

School Registration Form

Registration Form for 2024-2025 Academic Year and Student(s) Emergency Contact and Medical Information Form

Student 1 / Medical Information

Child's Name: *

Date of Birth: *

Age Grade: *

Gender: *

Male

Female

Programs to be Enrolled (Choose any combination): *

Sunday School

Quran Academy

Hospital/ Clinic Preference:

Physician's Name:

Phone Number:

Insurance Company:

Policy Number:

Allergies/Special Health Considerations:

Student 2 / Medical Information

Child's Name:

Date of Birth:

Age Grade:

Gender:

Male

Female

Programs to be Enrolled:

Sunday School

Quran Academy

Choose any combination

Hospital/ Clinic Preference:

Physician's Name:

Phone Number:

Insurance Company:

Policy Number:

Allergies/Special Health Considerations:

Student 4 / Medical Information

Child's Name:

Date of Birth:

Age Grade:

Gender:

Male

Female

Programs to be Enrolled:

Sunday School

Quran Academy

Choose any combination

Hospital/ Clinic Preference:

Physician's Name:

Phone Number:

Insurance Company:

Policy Number:

Allergies/Special Health Considerations:

Student 3 / Medical Information

Child's Name:

Date of Birth:

Age Grade:

Gender:

Male

Female

Programs to be Enrolled:

Sunday School

Quran Academy

Choose any combination

Hospital/ Clinic Preference:

Physician's Name:

Phone Number:

Insurance Company:

Policy Number:

Allergies/Special Health Considerations:

Parent/Guardian 1 Information

Parent's/Guardian's Name: *

Home Phone: *

Cell Phone: *

Address: *

City: *

State: *

Zip: *

Email:

Parent/Guardian 2 Information

Parent's/Guardian's Name:

Home Phone:

Cell Phone:

Address:

City:

State:

Zip:

Email:

Primary Emergency Contact

Primary Emergency Contact Name:

Home Phone:

Cell Phone:

Address:

City:

State:

Zip:

Email:

Secondary Emergency Contact

Secondary Emergency Contact Name:

Home Phone:

Cell Phone:

Address:

City:

State:

Zip:

Email:

Please check the following if you agree: *

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.

I also release MSGD Inc., and Staff of the MSGD Inc., from liability in case of any accident during activities related to the School, if normal safety procedures have been invoked.

Name of Parent/Guardian submitting the form : *