2017 Stafford Summer Recreation Registration Form
Hello! Please fill out this form for each child you will be registering. We are looking forward to a great, fun-filled summer!!
Name of child:
Your answer
Age:
Your answer
Sex:
School District:
Your answer
Home Address:
Your answer
Home Phone Number:
Your answer
Mother's Name:
Your answer
Mother's Work/Cell Phone:
Your answer
Father's Name:
Your answer
Father's Work/Cell Phone:
Your answer
Babysitter's Name:
Your answer
Babysitter's Phone Number:
Your answer
In case of emergency, and mother/father/babysitter cannot be reached, who should we contact?
Your answer
Relationship to child (back-up emergency contact):
Your answer
Phone Number (back-up emergency contact):
Your answer
Please list any allergies, health conditions, medications, or other information that we should be aware of regarding your child:
Your answer
Who has permission to pick-up your child? Please list names.
Your answer
Do we have your permission for your child's photograph to be displayed on the Town's website regarding the Recreation Program?
This summer, we are focusing on physical activity and active play! How would you rate your child's current level of physical activity?
Stationary - not physically active at all
Extremely active - my child loves physical activity!
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