six_mile

Items marked with * are required.

Student Info

First Name*

Last Name*

Gender*

Male Female

Address*

City*

State*

Zip*

Home Phone*

Numbers Only

Email*

Confirm

Date of Birth*

mm/dd/yy

Age*

Last School Grade Completed*

Home Church

City

State

Brother's or Sister's Name

Other

Name of special friend your child might like to be with

Need Transportation?*

Yes No

Parent/Guardian Info

First Name*

Last Name*

Home Phone*

Number's Only

Mom's Cell

Number's Only

Mom's Work

Number's Only

Dad's Cell

Number's Only

Dad's Work

Number's Only

Allergies/Medical Conditions

Emergency Contact*

Phone Number*

Number's Only

Relationship to the Child*

Person other than Parent Authorized to Pick up Your Child

Do You Agree the Above is Correct*

Yes No

You are also affirming that you are at least 13 years of age.

Please select three random boxes