Registration

Child Information
Child Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Gender*
Ethinicity (optional)
- Asian
- Black or African American
- Hispanic or Latino
- Native American or American Indian
- Native Hawaiian or Other Pacific Islander
- White
- Other
School Name*
Grade*
T-shirt Size*
How did you hear about our Summer Enrichment Program?*
- PHX Newsletter
- Social Media
- BUMC Communications e-mail
- E-mail
- Word of Mouth
- Other
If you selected "Other," please explain how you heard from the PopHealth Experience Summer Enrichment Program. Thank you.*

Parent/Guardian - Contact Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
Alternate Phone
Email*

Parent/Guardian #2 - Contact Information
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone
Alternate Phone
Email

Emergency Contact #3 - Contact Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
Alternate Phone
Email
Relation to Child*
Please list any people in addition to parents/guardians who are permitted to pick up your child and their relation to the child as well as their phone number (please note that anyone picking-up a program participant must be over 18 years old):*

Medical Information
Medical Insurance Policy Number*
Health Insurance Provider*
Name of Child's Primary Care Physician*
Primary Care Physician's Phone*
Hospital or Clinic*
Hospital or Clinic's Address*
Please list any medical conditions, including any conditions that require the use of medication during the summer program (i.e. Diabetes, Asthma etc.).
Is your child CURRENTLY being treated for an injury or sickness, or taking any form of mediation for any reason?*
- Yes
- No
Please explain.
Is your child allergic to any type of food or medication?*
- Yes
- No
Please list any food or medication that your child may be allergic to or any other dietary restrictions.
Please read and accept the following statement:*
The information provided on this form is accurate to the best of my knowledge. I have indicated any special health conditions, including required medication which should be known to the program staff. I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. I understand that Boston University and the Population Health Exchange are not responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.
I agree

Payment Information
PopHealthExperience Early-Bird Registration*
Coupon
Total
$0.00
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Credit Card
Card Details
Cardholder Name

PopHealthExperience Registration