Child's Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Address *

Include mailing address on line 2 if different

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone (Primary) *

(###)

###

####

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Age Information *

Birth Date

MM

DD

YYYY

Emergency Contact 1 Name *

First Name

Last Name

Emergency Contact 1 Phone Number *

(###)

###

####

Emergency Contact 2 Name

(optional)

First Name

Last Name

Emergency Contact 2 Phone Number

(optional)

(###)

###

####

May we have permission to photograph your child? *

Yes

No

May we have permission to use your child's photograph for the purpose of promotion? *

Yes

No