Come Read with Me
Student Registration Form
It is necessary that we have a hard copy of current
contact and medical information for each student signed by the student and
their guardian. Please advise if telephone numbers or medical needs change. Please
fill out the page, sign it then bring it to class when you come or return it by
mail to: Come Read with Me,
Cylinda Marshall at
817-797-5411, cylinda.marshall@verizon.net
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STUDENT
INFORMATION |
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Name |
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Nickname Date of Birth |
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Street Address |
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City
State
Zip |
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Student Home Phone |
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Student Cell Phone |
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Student Email |
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PARENT OR GUARDIAN INFORMATION |
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PARENT OR GUARDIAN |
PARENT OR GUARDIAN |
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Name |
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Address if Different From Student |
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Home Phone |
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Cell Phone |
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Work Phone |
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Email |
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EMERGENCY
CONTACT INFORMATION |
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Name |
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Relationship |
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Home Phone |
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Cell Phone |
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Work Phone |
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Come Read with Me
Student Registration Form
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MEDICAL
INFORMATION |
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Is there
any medical information that might be necessary for teaching staff to know? |
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To join
SNAP, please contact Rita Goodner (817) 481-6522 or Marlene Turner (817)
514-0944.
I
____ give ____ do not give
my permission to share contact information with other students for the
purpose of sharing rides or attaining transportation services from other
agencies.
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Student Signature |
Date |
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Parent/Guardian Signature |
Date |
____I am currently receiving these services through
MHMR:
____ Service Coordination
____ In-Home and Family Support (IHFS)
____
____ CLASS
____ HCS
Name of service coordinator ____________________________________________________________________________
Name of Private Provider you have chosen
____________________________________________________________________________
____I am not currently receiving services, but would like help in obtaining them.