Student Name *

First Name

Last Name

Session Selection: AGES 5-7

Mondays/Tuesdays 3-5pm *select all that apply

SEPTEMBER (dates: 14, 15, 21, 22, 28, 29)

OCTOBER (dates: 5, 6, 19, 20, 26, 27)

NOVEMBER (dates: 2, 3, 9, 10, 16, 17)

DECEMBER (dates: 7, 8, 14, 15)

Session Selection: AGES 8-12

Wednesdays/Thursdays 3-5pm *select all that apply

SEPTEMBER (dates: 16, 17, 23, 24, 30, Oct 1)

OCTOBER (dates: 7, 8, 21, 22, 28, 29)

NOVEMBER (dates: 4, 5, 11, 12, 18, 19)

DECEMBER (dates: 9, 10, 16, 17)

Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

EC Phone *

(###)

###

####

Anyone else authorized to pick up child?

First Name

Last Name

Up to date on vaccinations? *

Yes

No

Almost

If yes, please select reaction:

ANAPHYLACTIC REACTION: systemic, difficulty breathing, REQUIRED EPI-PEN

LOCALIZED REACTION: Pronounced swelling at the site of the sting, REQUIRED BENADRYL

Minimal localized reaction, did not require treatment

I agree to the TERMD and CONDITIONS above *

Yes

PHOTO/VIDEO Release *

I AGREE to the PHOTO/VIDEO release

I DO NOT AGREE to the PHOTO/VIDEO release