Child's Name (if two children -- fill out a second form) *
Your answer
Child's date of birth *
Your answer
We will be serving snacks. Any allergies or other pertinent medical information needed to provide a safe program? *
Your answer
All three days are the SAME PROGRAM. Please choose ONE day. Each day is limited to 8 participants. *
Required
In case of an emergency and the guardians listed above cannot be reached, who is another person we can contact and/or release your child to if needed? Please include name and phone number. *
Your answer
My child's picture may be used on One Prevention Alliance's Facebook or website? *
Anything else I should know to best serve your child and/or meet his or her needs? *
Your answer
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