Parent/Guardian Name *

Phone Number *

Email Address *

Address *

Place of Employment

Which program are you signing up for?

If you are registering for a holiday camp please indicate the specific camp here.

Child's Name *

Date of Birth *

Grade *

School Name *

Academic Concerns

Allergies/Physical Conditions *

Behavioral/Developmental Challenges (we ask so we can help support your child)

Emergency Contact *

Emergency Contact Phone Number *

Everyone who is allowed to pick up your child *

I give LFE Center permission to use my child's photos for their promotional material (e.g. website, social media, blog, flyer). Your child's photos will not be used for any other purposes outside of marketing material.

Anyone who is NOT allowed to pick up your child

Insurance Company

Family Physician & Phone Number

Hospital Preference

First and Last Name on Billing Credit Card *

Billing Address (if different from address above)

Credit Card Type (card will not be charged until the start date)

Credit Card Number

Expiration Date (mm/yy)

Card Identification Number (3 digits on back of card)