Summer Entrepreneurship Program

Summer Entrepreneurship Program
Parent Name

First NameLast Name
Parent Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PERSON TO CONTACT IN CASE OF EMERGENCY

(must be 18 years old and above)
Emergency Contact

First NameLast Name
Emergency Contact Telephone Number

Area CodePhone Number
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Please List Your Child's Medical Needs:
If none please type N/A.
Please List Your Child's Allergies:
If none please type N/A.
Emergency Pick-up

First NameLast Name
Contact Number
Emergency Pick-up

First NameLast Name
Contact Number
Email
example@example.com
Student's Signature
Parent/Guardian's Name

First NameLast Name
Parent/Guardian's Signature
Should be Empty: