Participant Information
Childs Name: *
Childs Name:
Any food allergies: *
Birthdate: *
Birthdate:
Phone Number:
Phone Number:
Is participant covered under health Insurance? *
Subscriber D.O.B.
Subscriber D.O.B.
Parent / Guardian Information
Parents Name: *
Parents Name:
Work Phone Number: *
Work Phone Number:
Cell Phone Number: *
Cell Phone Number:
Employer Address:
Employer Address:
Secondary Parent / Guardian Name:
Secondary Parent / Guardian Name:
Work Phone Number:
Work Phone Number:
Cell Phone Number:
Cell Phone Number:
Birthdate:
Birthdate:
In Case of Emergency
Name of local friend or relative (not living at same address): *
Name of local friend or relative (not living at same address):
Cell Phone Number: *
Cell Phone Number:
Work Phone Number: *
Work Phone Number:
Pick Up Permissions
The Following persons are permitted to pick up my child:
Name 1:
Name 1:
Name 2:
Name 2:
Name 3:
Name 3:

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