Participant Registration-Child

Leisure Days Registration 2025

Intergenerational Day Program: Child Enrollment
Parent/Guardian Info
Name*

First NameLast Name
e-mail*
Primary Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact (If Parent/Guardian cannot be reached)*
Relationship to Child*
Emergency Phone*

Area CodePhone Number
Billing Info

Our program cost is $15/registered day per child. We bill at the end of each month
Billing Infomation differs from Parent/Guardian Information
Please note: Parent/Guardian listed above assumes primary responsibility for account maintenance. Billing Info is for contact information only.
Billing Name*

First NameLast Name
e-mail*
Primary Phone Number*

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child Info
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age
New or Returning Participant?*

Returning ParticipantNew Participant
2025 Program Selection*
Is there anything you would like us to know about your child?
Add Another Child?

Add Participant 2
Child 2 Info
Participant Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age*
New or Returning Participant?*

Returning ParticipantNew Participant
Program Selection*
Is there anything else we need to know about your child?
Free Trial Day

If you are a new participant and would like to try our program, please select a Tuesday that works for you.
Date

MonthDayYear
Date
Terms and Conditions
Today's Date

MonthDayYear
Date
By checking 'I Agree' below and submitting this form, you, the Parent or Guardian of the above child(s), agree to pay the fees acuired while your child is participating in our program. You also agree that you are responsible ensuring your child is in good health when attenidng our program and you will keep your child home if they are too unwell to participate. You also give your permission for the public display of any program visual images that your child may appear in.
I Agree
Should be Empty:

Leisure Days Registration 2025

Parent/Guardian Info

Billing Info

Child Info

Child 2 Info

Free Trial Day

Terms and Conditions