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YMCA Schools Out Registration Form 2021/2022
Participant Information
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* Indicates required question
Childs Name
*
Your answer
School Attending
*
Pleasant View Elementary
Old County
LaPerche (Please note LaPerche will be based on a minimum enrollment)
Male/Female
*
Male
Female
Date of Birth
*
MM
/
DD
/
YYYY
Child's Age
*
Your answer
Grade Entering
*
K
1
2
3
4
5
DHS # (state pay students only)
Your answer
Address
*
Your answer
Town
*
Smithfield
Greenville
Other:
State
*
RI
Zip Code
*
02917
02828
Other:
Parent 1/Guardian 1
*
Your answer
Parent 1/Guardian 1 Email
Your answer
Parent 1/Guardian 1 Cell Phone
*
Your answer
Parent 1/Guardian 1 Place of Work
Your answer
Parent 1/Guardian 1 Work Phone
Your answer
Parent 2/Guardian 2
Your answer
Parent 2/Guardian 2 Email
Your answer
Parent 2/Guardian 2 Cell Phone
Your answer
Parent 2/Guardian 2 Place of Work
Your answer
Parent 2/Guardian 2 Work Phone
Your answer
Child Resides With
*
Mother
Father
Both
Guardian
Other:
Emergency Contact Name (Will be included on the "Approved Pick Up List)
*
Your answer
Emergency Contact Cell Phone
*
Your answer
Emergency Contact Home Phone
Your answer
Emergency Contact Relationship
*
Your answer
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