Date

Child Name

Age

School Attend

Grade in fall

Cell Phone

Gender GenderMaleFemale

Email

Address

City

State

Parent Name

Parent Cell Number

Emergency Contact

Emergency Contact Cell

Emergency Contact

Emergency Contact Cell

Emergency Contact

Emergency Contact Cell

Who will pick up your child each day?

Pick-up Person Cell Number

Please list any medications, allergies & medical conditions we should be aware of

Consent Consent I give my permission for my child to participate in the Huber KIDZ Summer Youth Program. I understand that aspects of the project will be photographed or filmed as a part of the projectand may be published online. I will provide/arrange for transportation and will be on time to drop off/pick up my child. I will inform the directors of any absences as far in advance as possible. I will provide a sack lunch including a drink each day for my child, some clothing for costumes (if requested) and agree to pay program fee ($100).* I agree to these guidelines.