Clone of 2025 Summer Club Registration

ENGAGE SUMMER CLUB REGISTRATION
Child's Name

First NameLast Name
Grade Child Is Entering in Fall 2026
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

May 27, 9 a.m. to 12 p.m. (pick up 12-1 p.m.)June 3, 9 a.m. to 12 p.m. (pick up 12-1 p.m.)June 17, 9 a.m. to 12 p.m. (pick up 12-1 p.m.)June 24, 9 a.m. to 12 p.m. (pick up 12-1 p.m.)July 1, 9 a.m. to 12 p.m. (pick up 12-1 p.m.)July 15, EVENING Observatory TripJuly 22, 9 a.m. to 12 p.m. (pick up 12-1 p.m.)July 29, 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? (Required for students who are younger than 5th grade)

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