Child's Name *

First Name

Last Name

Gender *

Male

Female

Date of Birth *

MM

DD

YYYY

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

####

Primary Care Giver *

First Name

Last Name

Secondary Care Giver

First Name

Last Name

Primary Cell Number *

(###)

###

####

Secondary Cell Number

(###)

###

####

The Child May Only Be Released To The Person Signing This Agreement Or To The Following:

First Name

Last Name

Address of Alternate Pick-up Person

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number for Alternate Pick-up Person

(###)

###

####

Persons To Contact In The Event Of An Emergency When Parents Cannot Be Reached: *

This person must be local and able to pick of child when parent is unavailable

First Name

Last Name

Alternate Emergency Contact *

(###)

###

####

Does Child Have Allergies (Insects, Medication, Foods, Etc.)?

Yes

No

Is Child on any Regular Medication? *

Yes

No

Primary Guardian *

First Name

Last Name

Secondary Guardian

First Name

Last Name