*<required field>

*Last name of Child:
Please use a separate form for each child in family.

Child

*Child's Full Name:

Likes to be called:

*Gender: Boy Girl

*Date of Birth: (mm/dd/yyyy)

Grade (as of 1/1/2008):

School:

Parents

*Parent 1:

*Home Phone:

Cell Phone:

Parent 2:

Work Phone:

Cell Phone:

Comments, pertinent information, or special needs? Are there any food allergies or food restrictions? Medical/physical needs?

Does your child have any social/emotional needs that we should know to help him/her function better in a group setting?

If there will be any person picking up your child other than the parents listed above, please list them below.