One form per student, per class taken.

Class registering for ______________________  Day(s) &Time(s) it meets:  __________________

Student _______________________ Cell phone _____________Email: _______________________

                    First and last name

Date of birth ________________________ Grade level for 2011-12 school year _______________

Mom: ____________ Phone: ______________ ______________ Email: ______________________

                Name                                           Home                                   cell

Dad: _____________ Phone: ______________ ______________ Email: ______________________

                Name                                           Home                                   cell

Additional emergency contact names and numbers: ______________________________________

__________________________________________________________________________________

Parent Address: ____________________________________________________________________

1. Is your child taking any medication I should know of? There is no nurse on staff to administer medications, so please indicate that the child can medicate himself.

2. Insurance information in case of emergency treatment—please list insurance company name and policy number to give to emergency personnel if needed.

3. List any medical situation for this child, including allergies, that I should be aware of. (Teachers will not be responsible for overseeing what students eat between or during classes.)

Please read and sign the following:

• In the event of an emergency, I hereby authorize a leader of this class or off-site field trip to secure appropriate medical care for my child(ren) listed above until a parent or guardian is present in person.
• I hereby release Dunwoody Classes and Margaret Shuman from all legal claims and liabilities which arise from participation in this class. 

Date:_______________________________ Parent Signature ________________________________

Please mail: This form and $35 check made out to Image Production and Staging (the Shumans’ business) for each class.  Send to Margaret Shuman’s bookkeeper, Caryn Becker, whose address is 4094 Flintridge Dr, Stone Mtn, GA  30083. You may contact her with questions at beckerb@bellsouth.net.

Please contact Margaret Shuman at pmpshuman@aol.com or 404-508-8318. She will be happy to speak to you in person and work out questions you may have!

PLEASE TURN IN ONE FORM PER STUDENT PER CLASS TAKEN.