2021 SUMMER KIDS CLUB REGISTRATION
Please complete 1 form for each child

We must have an average of 10 children per week in order to run the program.
We will make the decision on May 28th
Child's First Name *
Child's Last Name *
Age *
GRADE
GENDER
PARENT'S NAME *
MAILING ADDRESS
TOWN
ZIP
BEST PHONE # *
2ND PHONE #
BEST EMAIL *
SECOND EMAIL
EMERGENCY CONTACT NAME *
NOT PARENTS
EMERGENCY CONTACT PHONE # *
APPROXIMATELY HOW MANY DAYS A WEEK WILL YOU ATTEND
WHICH WEEKS DO YOU PLAN ON ATTENDING
ANY HEALTH ISSUES STAFF SHOULD BE AWARE OF
Please include allergies, or any medical conditions
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