• Child's Name*
  First NameMiddle NameLast Name
• Child's Date of Birth*
   -Month -DayYear

  Date
• Child's Home Address*
  Street Address

  Street Address Line 2

  CityState / Province

  Postal / Zip Code
• Parent/Guardian Name 1*
  First NameLast Name
• Parent/Guardian 1 Address (if different from child)
  Street Address

  Street Address Line 2

  CityState / Province

  Postal / Zip Code
• Parent/Guardian Name 2
  First NameLast Name
• Parent/Guardian 2 Address (if different from child)
  Street Address

  Street Address Line 2

  CityState / Province

  Postal / Zip Code
• Emergency Treatment and Transportation Authorization*
  Parent/Guardian Signature
• Off Premises Activities Authorization*
  Parent/Guardian Signature
• Submit
• Should be Empty: