Child's Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Please Choose One *

Male

Female

Please Choose All That Apply

Free/Reduced Meal

TANF Qualified

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Phone Number *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Primary Phone # *

(###)

###

####

Secondary Phone

(###)

###

####

Name #1 *

First Name

Last Name

Phone #1 *

(###)

###

####

Name #2

First Name

Last Name

Phone #2

(###)

###

####

Name #3

First Name

Last Name

Phone #3

(###)

###

####

Please choose one. *

I would like to pay the full amount upfront.

I would like to pay weekly.

I would like to apply for financial aid.

Would you like to volunteer during the week and/or on field trips?

No, thank you.

Yes, I'd like to help out on field trips.

Yes, I'd like to help out during the week.

Yes, I'd like to help out at both.

I'm not sure, please contact me with more information.