Mid-Week Registration

Forms

CHILD #1 INFORMATION
Last Name:	First Name:
Age:	Birthday:	Gender:
School Grade 09-10:	School Attending:	School City:
Allergies:
Does your child have any special learning needs that we should know about?

Name and address of a friend you would like to invite to Midweek:

CHILD #2 INFORMATION
Last Name:	First Name:
Age:	Birthday:	Gender:
School Grade 09-10:	School Attending:	School City:
Allergies:
Does your child have any special learning needs that we should know about?

Name and address of a friend you would like to invite to Midweek:

CHILD #3 INFORMATION
Last Name:	First Name:
Age:	Birthday:	Gender:
School Grade 09-10:	School Attending:	School City:
Allergies:
Does your child have any special learning needs that we should know about?

Name and address of a friend you would like to invite to Midweek:

CHILD #4 INFORMATION
Last Name:	First Name:
Age:	Birthday:	Gender:
School Grade 09-10:	School Attending:	School City:
Allergies:
Does your child have any special learning needs that we should know about?

Name and address of a friend you would like to invite to Midweek:

PARENT/HOME INFORMATION
Parent Name(s):
Address:
City:	Zip Code:
Home/Contact Phone:	Email:
Dad's Cell:	Mom's Cell:
EMERGENCY CONTACT INFORMATION
Emergency Contact Name(s):
Emergency Phone Number: