Summer Program 2025

Student first name:

Student last name:

Students email:

Students phone:

Student DOB:

Student age:

Student grade:

Parent first name:

Parent last name:

Parents email:

Parents phone:

Address:

We require contact info for 2 emergency contacts:

Emergency contact #1 first name:

Emergency contact #1 last name:

Emergency contact #1 relationship:

Emergency contact #1 phone:

Emergency contact #2 first name:

Emergency contact #2 last name:

Emergency contact #2 relationship:

Emergency contact #2 phone:

Student t-shirt size:

Student clothing sizes:

Does your child have any allergies that we should be aware of?

Yes

If yes, please describe the allergy and what protocol should be used in the event of a reaction?:

Is there anything else you would like us to know about your child, such as medical conditions, special needs, etc.?:

My child has permission to sign themselves in and/or out of the program:

Yes

I give permission for my child to be photographed and videotaped during program activities:

Yes

Payment:

Registration Fee:$425

Parent Signature:

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