Summer Adventure Registration Form

Child's Name*
First Last
Child's Date of Birth*
Month
Day
Year
Last Grade Completed*
Parent/Guardian Name*
First Last
Parent/Guardian Cell Phone*
Home Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Email
Enter Email Confirm Email
Emergency Contact Name*
First Last
Emergency Contact Phone*
Medical or other information we need to know about your child (Please include all allergies). If there are none please write N/A in the box below*
Dismissal Information - Who may pick up your child at the end of each night?*