MIDDLE KINGDOM PAGE SCHOOL AUTHORIZATION TRACKING FORM

 Arts/Sciences

 Service

 Chivalry

   

 

PARTICIPANT’S COPY

KEEP THIS COPY FOR YOUR RECORDS

PROVIDE ALL INFORMATION REQUESTED BELOW (PLEASE PRINT LEGIBLY AND FILL OUT BOTH HALVES OF THIS FORM)

SCA NAME

DATE

PLEASE INDICATE LEVEL BELOW

FULL MODERN NAME

EVENT

JUNIOR PAGE

STREET ADDRESS

SENIOR PAGE

CITY

STATE/PROV

POSTAL CODE

GRADUATE PAGE

TELEPHONE

EMAIL ADDRESS

DATE OF BIRTH

NAME OF

ACTIVITY (BE SPECIFIC)

ACTIVITY LOCATION

NUMBER OF ACCREDITED HOURS

TEACHER SIGNATURE

TEACHER SIGNATURE (IF MORE THAN ONE CLASS)

Created: 1/03

– – – – – – – – – – – – – – – – – – – – – – – – – – – <SEPARATE FORMS HERE> – – – – – – – – – – – – – – – – – – – – – – – – – –

MIDDLE KINGDOM PAGE SCHOOL TRACKING FORM

 Arts/Science

 Service

 Chivalry

   

 

DEAN OF THE PAGE SCHOOL’S COPY

SEND THIS FORM TO THE DEAN OF THE PAGE SCHOOL

PROVIDE ALL INFORMATION REQUESTED BELOW (PLEASE PRINT LEGIBLY AND FILL OUT BOTH HALVES OF THIS FORM)

SCA NAME

DATE

PLEASE INDICATE LEVEL BELOW

FULL MODERN NAME

EVENT

JUNIOR PAGE

STREET ADDRESS

SENIOR PAGE

CITY

STATE/PROV

POSTAL CODE

GRADUATE PAGE

TELEPHONE

EMAIL ADDRESS

DATE OF BIRTH

NAME OF

ACTIVITY (BE SPECIFIC)

ACTIVITY LOCATION

NUMBER OF ACCREDITED HOURS

TEACHER SIGNATURE

TEACHER SIGNATURE (IF MORE THAN ONE CLASS)

INSTRUCTIONS:

Give the participant this whole, completed form.

Created 1/03