DATE
MM
DD
YYYY
SCHOOL ATTENDING
GRADE
PARENT’S NAME
*
First Name
Last Name
ADDRESS
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
PHONE
(###)
###
####
EMAIL
*
NAME
RELATION
PREFERRED NAME
DOB
MM
DD
YYYY
AGE
NAME
RELATION
PREFERRED NAME
DOB
MM
DD
YYYY
AGE
NAME
RELATION
PREFERRED NAME
DOB
MM
DD
YYYY
AGE
NAME
RELATION
PREFERRED NAME
DOB
MM
DD
YYYY
AGE
EMERGENCY CONTACT NAME
RELATION
CELL
(###)
###
####
OTHER
EMERGENCY CONTACT NAME
RELATION
CELL
(###)
###
####
OTHER
Out of School Programs:
Education:
Creative Arts
Recreation
Visual Arts
Computer Science
Other
*
*
*
*
*
*
(I) (We), HAVE READ THIS DOCUMENT AND UNDERSTAND THAT IT IS A RELEASE OF ALL CLAIMS ANDTHAT ALL ABOVE INFORMATION REQUESTED IS TRUE AND ACCURATE.
*
SIGNATURE
*
DATE
*
MM
DD
YYYY
