| I am registering for: | |
| |
| Child's First Name | |
| Child's Last Name | |
Address | |
City | |
State | |
Zip | |
| ParentsGuardians Name | |
Home Phone | |
Work Phone | |
Cell Phone | |
| Email | |
| Grade Just Completed | |
| Gender | M F |
| Birthdate | |
| Age | |
| Allergy Medical Conditions | |
Who other than parents guardians
may pick up this child | |
| Emergency Contact name and number | |
| T-Shirt Size | |
| | |