* = Required Information

   

Child Information
 
Last Name *
First Name *
Date of Birth *
Health Card Number *
Allergy or Medical Information
Activities Select which ones your child will be included in                     Camp Only
                    Outing
                    Extended Hours (3:00pm - 5:00pm)

Parent/Guardian Information
 
Last Name *
First Name *
Address *
Street, City, State
City
Postal Code
Home Phone *
Cell Phone
Work
Email Address *

In Case of Emergency:
 
Full Name *
Phone *

Other Information
 
Authorized Person(s) who will pick up your child *
How did you hear about us
Referred By:
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