Summer Program Registration Form

Child Information

Child's Name

First NameLast Name

Birth Date

MonthDayYear

Grade (as of next school year)

Gender

MaleFemale

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Information

Name

First NameLast Name

Home Number

Area CodePhone Number

Cell Number

Area CodePhone Number

E-mail

Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Molly Dickerson during the selected session.

Details and Information

The links for the zoom meeting each day will be sent out to the email you have provided. A lunch will be expected to be prepared by a parent, guardian, sibling, or other person in the household, so as not to take any time away from the activities we have planned. If there are any further questions, contact me at (781) 434-9536 or molly.r.dickerson@gmail.com

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.