If you would like to register more than one child, please resubmit a second form upon submisssion of this one. Please check which program or programs you would like your child to attend: * Kids Program - Ages : 7-11 (School year : 4pm - 6:30pm) Pre-teen Program - Ages : 12-14 (School year: 6:30pm - 7:30pm) Summer Program - Ages : 7-12 ( JUL - AUG ) My child has permission to walk home alone * Yes No Please choose T-shirt Size: * - Select -Youth SmallYouth MediumYouth LargeYouth X Large CHILD INFORMATION: Gender * Male Female Name (First & Last) * Email Address Street Address * City * State * Zip/Postal Code * Home Phone Date of Birth: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 CHILD MEDICAL INFORMATION: Health Insurance Policy Number List any Allergies List any Medical Conditions List any Medications PARENT #1/GUARDIAN: Name (First & Last) * Street Address * City * State * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip/Postal Code * Home Phone Cell Phone * Work Phone Relationship to Child: * Mother Father Guardian Other PARENT #2/GUARDIAN: Name (First & Last) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip/Postal Code Home Phone Cell Phone Work Phone Relationship to Child: Mother Father Guardian Other EMERGENCY CONTACTS: (in addition to parents/guardians) Name * Address Relationship Cell Phone * Home Phone Name Address Relationship Cell Phone Home Phone