Child Information
Child's First Name (required)
Child's Last Name (required)
Child's Gender (required) FemaleMale
Child's Date of birth (required)
Child's Age (required)
Child's t-shirt size (required)
School Name (required) ---GreenwoodMcKinleyTaftEisenhowerMadisonCoolidgeOther
Grade in Fall 2018 (required) ---KindergartenFirstSecondThirdFourthFifthSixthSeventhEighth
Please list any specific needs of your child.
Please list any known allergies of your child.
Please list all medications your child is taking.
Does your child have a public library card? (required) YesNo
Can your child swim? (required) YesNo
Program enrollment Information
Select your child's enrollment (required) ---Summer ProgramAfter SchoolBefore and After SchoolBefore School
Payment options: (required) ---pay 1 payment in fullpay in 2 installments (with additional $20 administrative fee)pay in 3 installments (with additional $30 administrative fee)
Part-time schedule only - list the days/weeks service is needed
Tell us about your child
My child's strengths are:
My child needs practice with:
My child enjoys:
What are your expectations for your child while participating in our program:
Parent/Guardian Information
First Name (required)
Last Name (required)
Address (required)
City (required)
State (required)
Zip Code (required)
Preferred Phone Number (required)
Parent Email address (required)
Who does your child live with? (Please list names/relationships)
Emergency Contact
Name (required)
Phone Number (required)
Relationship to child (required)
Who is authorized to pick up your child?
How did you hear about us? (required)
