Use Your Noodle Summer Registration                                        
Dates: June 17-21, June 24-28, July 8-12, July 15-19
Time: 8:00am -3:00pm
Where: Avondale Samaritan Place, 3829 5th Avenue South 35222
Who: Students completing Kindergarten - Students completing 3rd grade
Cost: $10 (includes tshirt), due first week of camp, cash or check

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Student Name *
Student Date of Birth *
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/
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/
YYYY
Gender *
What grade is student completing this spring (2024)? *
Home address of student (street, city, state, zip code) *
Race *
School Student Attends *
Name of Parent/Guardian #1 *
Phone number of parent/guardian #1 *
Relationship of Parent/Guardian to student *
Can parent/guardian #1 receive texts? *
Please type email address for parent/guardian #1 below or type NA for not available *
Name of parent/guardian #2
Relationship of parent/guardian #2 to student
Phone number of parent/guardian #2 
Can parent/guardian #2 receive texts?
Clear selection
Please type email for parent/guardian #2 below or type NA for not available
Please list name of anyone else who has permission to pick up your student.
Phone number(s) for anyone else who has permission to pick up your student.
Emergency contact name (s) *
Emergency contact phone number (s) *
Student tshirt size  *
Please list any food allergies or health concerns below
Please list any medications you are leaving with us below, along with dosing instructions
Does your student receive special services at school? *
If yes, please explain below
Does your child receive ESL services? *
What languages are spoken in your home? *
In case of emergency, the staff has my permission to seek medical attention for my child *
I agree that the program may utilize photographs, slides and videos of my student, and I understand that I will not receive compensation for such use. *
Is there anything else you would like for the staff of UYN to know about your child?
Parent/Guardian signature and date: *
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