Please fill out this registration form. All information will be kept confidential.

Child's Name *
Child's Name
Please give full name with nickname in parenthesis
Child's Birth Date *
Child's Birth Date
Child's Parent/Guardian Name *
Child's Parent/Guardian Name
Parent/Guardian Phone Number *
Parent/Guardian Phone Number
Other Emergency Contact
Other Emergency Contact
Other Emergency Contact Phone Number
Other Emergency Contact Phone Number
Dinner *
Please let us know which evenings you will be here for dinner.

COST

$10.00 per child