Child's Name *

Child's Name

First Name

Last Name

Child's Gender * Boy Girl

Child's Age *

Must be 3 by June 1

3 yrs (by June 1) 3 yrs 4 yrs 5 yrs 6 yrs 7 yrs 8 yrs 9 yrs 10 yrs 11 yrs

Child's Birthday *

Child's Birthday

MM

DD

YYYY

Last Grade Completed * Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade

Parent's Name *

Parent's Name

First Name

Last Name

Email Address *

Phone *

Phone

(###)

###

####

Emergency Information

Allergies or other medical conditions

Emergency Contact Name *

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

Emergency Contact Phone

(###)

###

####

Relationship to Child *

Thank you!