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Wrap
Text File
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1993-03-26
|
3KB
|
68 lines
Child's last name: ____________________ First:____________________ Age:________
Date of birth: ▀▀»▀▀»▀▀ Sex: Male█▀▌ Female█▀▌
Parent Information:
╠ß≤⌠áεßφσ║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀á╞Θ≥≤⌠║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀á═ΘΣΣ∞σ║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀
Title: ____________________ Greeting: _________________________________________
╧≥τßεΘ·ß⌠Θ∩ε║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀
ááááá┴ΣΣ≥σ≤≤║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀
áááááááááááááá▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀
áááááááá├Θ⌠∙║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀á╙⌠ß⌠σ║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀á┌Θ≡║á▀▀▀▀▀▀▀▀▀▀
ááááá├∩⌡ε⌠≥∙║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀á┴⌠⌠ε║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀
Home phone: ¿▀▀▀⌐á▀▀▀¡▀▀▀▀ Business phone: ¿▀▀▀⌐á▀▀▀¡▀▀▀▀
Contact in emergency:____________________________________ Phone: ¿▀▀▀⌐á▀▀▀¡▀▀▀▀
Address: _________________________________________ Relationship: ______________
Persons authorized to pick up Child: 1. _______________________________________
2.__________________________________ 3. _______________________________________
4.__________________________________ 5. _______________________________________
Special medication: █▀▌ Kind: ________________________________________________
Permission to administer med. █▀▌ Permission to call physician █▀▌
Permission to treat ailments █▀▌ Physician __________________¿▀▀▀⌐á▀▀▀¡▀▀▀▀
Reservations: 1.▀▀»▀▀»▀▀ 2.▀▀»▀▀»▀▀ 3.▀▀»▀▀»▀▀ 4.▀▀»▀▀»▀▀ 5.▀▀»▀▀»▀▀
Advance payment: $▀▀▀▀▀▀«▀▀ Date:▀▀»▀▀»▀▀
4864 0 19 20 childs_name.lastname -1
4352 0 46 20 childs_name.firstname -1
12 0 71 8 childs_age. -1
3 1 15 8 birthdate.DATE 2 47 5 47 -1
8 1 39 3 sex_male.YESNO 0 91 2 93 -1
8 1 50 3 sex_female.YESNO 0 91 2 93 -1
4864 3 11 18 parent_name.LASTNAME -1
4352 3 37 18 parent_name.FIRSTNAME -1
4608 3 64 15 parent_name.MIDDLENAME -1
12 4 7 20 title. -1
12 4 38 41 greeting. -1
4353 5 14 65 address.ORGANIZATION -1
8449 6 14 65 address.ADDRESS1 -1
12545 7 14 65 address.ADDRESS2 -1
16641 8 14 21 address.CITY -1
16897 8 43 20 address.STATE -1
17153 8 69 10 address.ZIPCODE -1
20737 9 14 30 address.COUNTRY -1
20481 9 51 28 address.ATTENTION -1
2 10 12 14 home_phone.PHONE 0 40 4 41 5 32 9 45 -1
2 10 51 14 business_phone.PHONE 0 40 4 41 5 32 9 45 -1
12 11 21 36 emergency_contact. -1
2 11 65 14 emergency_phone.PHONE 0 40 4 41 5 32 9 45 -1
12 12 9 41 emergency_address. -1
12 12 65 14 relationship. -1
12 13 40 39 pickup1. -1
12 14 2 34 pickup2. -1
12 14 40 39 pickup3. -1
12 15 2 34 pickup4. -1
12 15 40 39 pickup5. -1
8 16 20 3 medication.YESNO 0 91 2 93 -1
12 16 31 48 medication_type. -1
8 17 32 3 administer_med.YESNO 0 91 2 93 -1
8 17 69 3 call_physician.YESNO 0 91 2 93 -1
8 18 31 3 treat_ailments.YESNO 0 91 2 93 -1
12 18 47 18 physician. -1
2 18 65 14 physician_phone.PHONE 0 40 4 41 5 32 9 45 -1
3 19 16 8 reservations1.DATE 2 47 5 47 -1
3 19 28 8 reservations2.DATE 2 47 5 47 -1
3 19 40 8 reservations3.DATE 2 47 5 47 -1
3 19 52 8 reservations4.DATE 2 47 5 47 -1
3 19 64 8 reservations5.DATE 2 47 5 47 -1
5 20 18 9 payment.MONEY 6 46 -1
131 20 56 8 date_enter.DATE 2 47 5 47 -1