Summer Program Registration Form

Ms. Mel's Wacky Registration Form
Child Information
Child's Name 1

First NameLast Name
Birth Date

MonthDayYear
Gender

MaleFemale
Grade
Child's Name 2

First NameLast Name
Birth Date

MonthDayYear
Grade
Gender

MaleFemale
Child's Name 3

First NameLast Name
Birth Date

MonthDayYear
Grade
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Any allergies, chronic illness, or medical conditions? If yes, please describe.
Parent/Guardian Information
Name

First NameLast Name
Home Number

Area CodePhone Number
Cell Number

Area CodePhone Number
E-mail
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Melanie Genanatti during the selected session.

I Herby give my approval for my child to be photographed while in attendace of events and field trips with Ms. Mel's Wacky Wednesday.

Details and Information

After acceptance into the program, you will receive a detail calendar of events, locations, and times for every Wednesday. Every Tuesday night you will recieve a reminder email with itenerary and any special details for the following day. Questions or concerns please contact me at 360-560-5811
Signature

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Registration
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Registration Fees
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Registration Fees

Registration Fees $20.00
This pays to hold your spot, and the initial supplies for set up cost

Family Registration Fees (2+)$35.00
Family registration is to hold places and help with early start up costs

Total $0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

Ms. Mel's Wacky Registration Form