2025 Fall Club Registration

ENGAGE FALL CLUB REGISTRATION
Child's Name

First NameLast Name
Grade Child Is Entering in Fall 2025
Child's Phone Number
Format: (000) 000-0000.
Child's Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sept. 20, 9 a.m. to 12 p.m. (pick up 12-1 p.m.)Oct. 11, 9 a.m. to 12 p.m. (pick up 12-1 p.m.)Nov. 8, 9 a.m. to 12 p.m. (pick up 12-1 p.m.)Dec. 13, 9 a.m. to 12 p.m. (pick up 12-1 p.m.)
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
Format: (000) 000-0000.
Work phone
Format: (000) 000-0000.
Email
example@example.com
General Medical History
YesNo
FoodMedicationEnvironmental
Please list and explain any allergies
List any ongoing Medical Conditions (asthma, seizures, headaches):
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 FALL CLUB REGISTRATION