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Child’s Name: ___________________________________ Date of Birth: _________________ Current Age: _____ CURRENT Classroom or Grade: (Check one) CNS Room 1 - 4 ______ CNS Room 6 - 12 ______ Kindergarten – 5th _____ New to CNS ______**All information regarding parents/guardians and emergency contacts will be used from the student’s most current registration form. Does your child have any food allergies? [ ] Yes [ ] No If yes, please list them. ______________________________________________________________________________________________________________________________________________________________________I give my permission for EMERGENCY MEDICAL TRANSPORTATION OR TREATMENT (If parents or emergency contacts cannot be reached): [ ] Yes [ ] NoI give my permission for the following to be applied to my child if needed:Sunscreen [ ] Yes [ ] NoBug Spray[ ] Yes [ ] NoNeosporin[ ] Yes [ ] NoI give my permission for my child to ride in the CNS van to and from scheduled field trips. [ ] Yes [ ] NoI give my permission for my child’s photo to be used for the CNS web page and Facebook page.[ ] Yes [ ] NoI have read and understand the 2018-2019 Parent Handbook. [ ] Yes [ ] No_________ (Please Initial) **AS STATED IN THE HANDBOOK, IF YOUR CHILD IS NOT PICKED UP BY 5:30 P.M. A LATE FEE OF $5.00 PER MINUTE WILL BE CHARGED TO YOUR CHILD’S ACCOUNT. IF YOU ARE LATE MORE THAN 3 TIMES, THEN YOU WILL BE REQUIRED TO PICK UP YOUR CHILD NO LATER THAN 5:15 P.M.___________________________________________________________Parent’s SignatureDate1981200-5334000I hereby authorize Clovis Nazarene School to initiate credit/debit card charges to the below-referenced credit/debit card account. I understand it is my responsibility, as the cardholder; to keep a reliable payment source on file at all times to avoid any additional fees for payments returned. If there is a payment arrangement made between an outside party and/or two separate households, each cardholder will need to complete a separate Tuition Express form.48387004572000CREDIT/DEBIT CARD:Cardholder Name: _______________________________________Phone Number: ___________________Address: ________________________________________City & State: ________________Zip: ________Card Number: _______________________________________ Expiration Date: ______________________Cardholder Signature: ____________________________________________ Date: ____________________For Office Use Only:Date Received:___________________Employee Initials: ................
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