Child's First Name

Child's Last Name

Child's Gender

Child's Grade in the Fall

Child's Date of Birth

Does child have any allergies?

Yes

No

Please list allergies here

Does child have any medical concerns?

Yes

No

Please list medical concerns here

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Relationship to Child

Parent/Guardian Phone Number

Parent/Guardian Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Parent/Guardian Email

In the event that we cannot reach the parent/guardian, please leave information for an emergency contact below.

Emergency Contact First Name

Emergency Contact Last Name

Relationship to Child

Emergency Contact Phone Number

Anything else we should know about?