Young Explorers Science Club

1

Name of Parent

First Name

Last Name

2

Name of Child 1

First Name

3

Age of Child 1

Age

4

Name of Child 2IF APPLICABLE

First Name

Last Name

5

Age of Child 2IF APPLICABLE

Age

6

Name of Child 3IF APPLICABLE

First Name

Last Name

7

Age of Child 3IF APPLICABLE

Age

8

Does your child require any special arrangements?Please state details below

9

Preferred Contact Number

Area Code

Phone Number

10

Email

example@example.com

11

Appointment