Child's Name *

First Name

Last Name

Second child's name (if applicable)

First Name

Last Name

Caregiver's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

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Select Dates *

Select all that apply. Registration is $60/day or $300/week per child (August program registration is for full week only)

Full Week February 17-21

Monday 2/17

Tuesday 2/18

Wednesday 2/19

Thursday 2/20

Friday 2/21

Full Week April 14-18

Monday 4/14

Tuesday 4/15

Wednesday 4/16

Thursday 4/17

Friday 4/18

Full Week August 25-29

Emergency Contact Name (Other than Caregiver)

First Name

Last Name

Emergency Contact Phone

(###)

###

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Additional Emergency Contact Name (Other than Caregiver)

First Name

Last Name

Emergency Contact Phone

(###)

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