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4th Grade Wall that Heals Memorial Wall Field Trip
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Registration
Free
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Participant's First Name
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Participant's Last Name
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Teacher's Name (or 1st period teacher)
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Current Grade
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Parent/Guardian First & Last Name
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Emergency contact #1
List name, and relationship. Must be over 21 years old.
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Emergency contact #1 phone number
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Emergency contact #2
List name, and relationship. Must be over 21 years old.
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Emergency contact #2 phone number
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Has your student's emergency or medical information changed since the beginning of the school year?
No
Yes
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If yes, please explain what changed
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I permit my student to be photographed, videotaped, or otherwise recorded during this field trip for educational and school-related publications, social media, or promotional purposes.
No
Yes
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I confirm that I am the parent or legal guardian of the student listed above and give my permission for my student to attend the field trip described in this form.
I agree
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