2007 DESIGNLAB After School Workshops

STUDENT INFORMATION FORM

  Name  _____________________________________                       M  ___   F  ___     

  street  _________________________________     town/zip _________________________

  home phone:  ______________________         

  school:  __________________________________________                     grade:  _______

  Do you identify yourself with a particular ethnic/minority group?

        Southeast Asian             African-American               Hispanic              other:____________         

  Parent/Guardian  ____________________________   relationship to student  __________

  street  _________________________________     town/zip _________________________

  home phone:  ________________________       work phone:  _______________________

   Another Person to Contact in Case of Emergency:

  Name  ________________________________   relationship to student  _______________

  home phone:  ________________________       work phone:  _______________________

Medical Information:  Does your child have any medical condition that could affect his/her performance in this workshop, or pose a danger when using tools?

NO                                          YES*

    Is your child currently taking any medication?

                                                                        NO                                          YES*

* Please list any medical conditions that could affect your child’s participation in our  

workshop.  Also, list all medications that your child is currently taking.