2008 Summer Program Registration

Page 1 of 2: Contact Information
Student Information
Please note that special characters (like !, #, $, %, &, *, +, and =) are not allowed in entry fields below.
Fields marked with an * (asterix) are required.
 *  *  *  *
First Name Last Name Age Birthday
 *
 *  *  *
 *
Street Address
City State Zip
Sex

Current School 		 *
Grade in Fall

Does your child have any allergies?  *
Yes No
If YES, please explain:
(Limit 50 words or less)
Doctor's Name:  * Doctor's Telephone:  *
Parent Information:
Mother
First Name  *
Last Name  *
Home Phone  *
Cell Phone  *
Work Phone  *
Email  *
Father
First Name  *
Last Name  *
Home Phone  *
Cell Phone  *
Work Phone  *
Email  *
Emergency Contact:
First Name  *
Last Name  *
Home Phone  *
Cell Phone  *
Additional people your child may be released to:
First Name  *
Last Name  *
Home Phone  *
Cell Phone  *
First Name
Last Name
Home Phone
Cell Phone

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