Palmyra-Eagle Community Education & Recreation YOUTH REGISTRATION FORM
Please ensure the information is COMPLETE and ACCURATE to ensure proper communication! 

You may choose up to 3 events PER CHILD on one form. If you'd like to do more, please fill out another form.
If you have multiple children doing events, please fill out the form once PER CHILD. 
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Email *
Class or Event Name *
Class or Event Name
Class or Event Name
Child's Name (First) *
Child's Name (Last) *
Preferred Name
Child Date of Birth *
MM
/
DD
/
YYYY
Current Grade *
Parent or Guardian Name(s) *
Mailing Address *
Parent/Guardian Phone Number(s) *
Parent/Guardian Email(s) *
Emergency Contact Name & Phone Number *
Who is allowed to pick up your child? *
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