2025 Summer Club Registration

ENGAGE SUMMER CLUB REGISTRATION
Child's Name

First NameLast Name
Grade Child Is Entering in Fall 2025
Child's Phone Number
Child's Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates Child Will Attend Summer Club

June 4, 9 a.m. to 12 p.m. (pick up 12-1 p.m.)June 11, 9 a.m. to 12 p.m. (pick up 12-1 p.m.)June 18, 9 a.m. to 12 p.m. (pick up 12-1 p.m.)June 25, 9 a.m. to 12 p.m. (pick up 12-1 p.m.)July 16, 9 a.m. to 12 p.m. (pick up 12-1 p.m.)July 23, 9 a.m. to 12 p.m. (pick up 12-1 p.m.)July 30, 9 a.m. to 12 p.m. (pick up 12-1 p.m.)
Will a guardian be staying during Summer Club and driving this student to the field trip location for the day?

YesNo
In Case of Emergency
Name

First NameLast Name
Relationship to student
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell phone
Work phone
Email
example@example.com
General Medical History
Does your child have any food, medication or environmental allergies?

YesNo
Allergies? Check all that apply

FoodMedicationEnvironmental
Please list and explain any allergies
List any ongoing Medical Conditions (asthma, seizures, headaches):
Is any medication required?

YesNo
List any medication taken regularly:
I consent to the following administration: sunscreen - topical product or lotion, exact dosage: liberal application per exposed area, to be administered: before high sun exposure.
Medical insurance details
Name of Insurance Company:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Number:
Expiry Date:

DayMonthYear
Should be Empty:

ENGAGE SUMMER CLUB REGISTRATION

In Case of Emergency

General Medical History

Medical insurance details