(complete one form per child)

Child's Name

First Name

Last Name

Date of Birth

YYYY

Age/Grade

Food Allergies

Please list any food allergies below:

Health Concerns

Please list any health concerns below:

Please list names of those who will drop off and pick up your child:

Please list names of those who CANNOT pick up your child:

Parent or Guardian Information:

Parent Name

First Name

Last Name

Parent Email

Parent Cell

(###)

###

####