How many adults will be attending?

How many children will be attending with you?

How did you hear about this program?

Multiple Households?

Adults/Guardians are in separate Households

Children's Household

Parent/Guardian 1Parent/Guardian 2

Adult/Guardian 1

First Name

Last Name

Cell Phone

Street Address

City

State

Postal Code

Date of Birth

Adult/Guardian 2

First Name

Last Name

Cell Phone

Street Address

City

State

Postal Code

Date of Birth

Child 1

First Name

Last Name

Date of Birth

Grade

Child 2

First Name

Last Name

Date of Birth

Grade

Child 3

First Name

Last Name

Date of Birth

Grade

Child 4

First Name

Last Name

Date of Birth

Grade

Child 5

First Name

Last Name

Date of Birth

Grade

Additional Information

Do you need any accommodations to make this experience meaningful?

Do you or your children have any allergies or health concerns? If so, please list.

I give permission for any photographs taken of my child(ren) be used for promotional purposes:

We consent to the Code of Conduct:

The adult facilitator can contact my child directly with program updates: