* = Required Information
Child's Name *	Date of Birth: *
Home Address: *
Home Phone: *	Email *
Mother's Name: *	Occupation
Work Phone	Cell Phone:
Father's Name: *	Occupation
Work Phone	Cell Phone:
Emergency contacts (other than parents)
Name:	Relation to child
Address:
Home Phone	Cell Phone:
Name:	Relation to child
Address:
Home Phone	Cell Phone:
Does child have any health condition that may affect participation in physical activities:	YesNo
Does child have any food allergies:	YesNo
List All
Days Requested (circle one):	Monday Tuesday Wednesday Thursday Friday
	Half-DayFull Day
Start Date:	Transition Dates:
Signature of Parent/Guardian	Relation to Child
Security Code *