Lamplighter Educational Resource Center
538 Main Street
Milford, OH 45150
(513) 831-6344

Summer Class Registration Form

Please print out, fill out completely, and send in with registration fees.

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Student Name:______________________________________________	Age:______________
Address:_____________________________________________________________________________
City                             State                     Zip Code
School:____________________________________________________	Grade:____________
Class:____________________ Instructor: __________ Dates:____________ Time:______ Cost:______
Class:____________________ Instructor: __________ Dates:____________ Time:______ Cost:______
In case of emergency, the Center must be able to reach a responsible adult:
Parent or Guardian:____________________________________	Phone:_________________
Alternate emergency number(s):___________________________________________________________
Physician:_______________________________________	Phone:_________________
Permission is granted to call a physician in case of an emergency.
Any student health or allergy problems of which we need to be aware? _________________
Is the student on any medication? _______       Are there any instructions for Center personnel? If there are, please indicate on the back of this sheet.

	_______________________________________ Signature of parent or guardian
	Date: ________________
Full payment must accompany class registration. If there is insufficient enrollment, money will be refunded. Parents are responsible for their children's transportation to and from the Center.