Registration Name * First Name Last Name Email * Student's Name * First Name Last Name Student's Birthday * MM DD YYYY Gender Male Female Days a Week * (Preschool available 2-5 days, Afterschool available 2-5 days) 2 3 4 5 Requested Days * Monday Tuesday Wednesday Thursday Friday Preschool Fall Preschool Summer Preschool Fall & Summer Preschool Elementary / Afterschool Fall Afterschool (Elementary Kids) Summer Camp Fall Afterschool & Summer Camp Elementary School (for Afterschool Program Only) Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Emergency Contact * First Name Last Name Emergency Contact Phone (###) ### #### Child Pickup Authorization * Please list Name, Relationship, and Phone for all those you authorize to pick up your child. Physician's Name * First Name Last Name Physician's Phone * (###) ### #### Preferred Hospital * Insurance Company & Policy # * Medical Conditions/Allergies * Anything else you want to message us? Thank you!
