Homenetmen Scouts Registration Form
Please fill out all fields. Thank you.
Child's First Name *
Child's Last Name *
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Parent/Guardian Name *
Street Address *
City *
State *
Zip Code *
Phone *
Email Address *
Name of Emergency Contact (Other than Guardian) *
Emergency Contact Phone *
Relationship to Participant *
Has the participant contracted Covid-19? *
If "Yes", how long ago?
Is the participant vaccinated for Covid-19? *
Please select if you want any further information on:
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