Adopt-A-Grandparent Program

Adopt-A-Grandparent Program

AAG is available for children 12 years old to teens 17 years old.
How many children are you registering?*
Child Information
First Child
Child's Name*

First NameLast Name
Child's Birth Date*

MonthDayYear
Last Grade Completed*
YesNoChoose not to answer
Where?
Medical or other information we may need to know about the child (including food allergies and/or medications).*
Second Child
Child's Name*

First NameLast Name
Child's Birth Date*

MonthDayYear
Last Grade Completed*
YesNoChoose not to answer
Where?
Medical or other information we may need to know about the child (including food allergies and/or medications).*
Third Child
Child's Name*

First NameLast Name
Child's Birth Date*

MonthDayYear
Last Grade Completed*
YesNoChoose not to answer
Where?
Medical or other information we may need to know about the child (including food allergies and/or medications).*
Fourth Child
Child's Name*

First NameLast Name
Child's Birth Date*

MonthDayYear
Last Grade Completed*
YesNoChoose not to answer
Where?
Medical or other information we may need to know about the child (including food allergies and/or medications).*
Child Release Information
Parent/Legal Guardian Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Names of Persons to which the child (children) may be released to each night after AAG (Please provide at least two)*

First NameLast Name
Full Name*

First NameLast Name
Full Name

First NameLast Name
Full Name

First NameLast Name
YesNo
Who may your child (children) NOT be released to?
Emergency Contact 1 (other than parent/guardian listed above)*

First NameLast Name
Emergency Contact 1 Phone Number*

Area CodePhone Number
Emergency Contact 2 (other than parent/guardian listed above)*

First NameLast Name
Emergency Contact 2 Phone Number*

Area CodePhone Number
Media Release
I Agree
Should be Empty:

Adopt-A-Grandparent Program

Child Information

First Child

Second Child

Third Child

Fourth Child

Child Release Information

Media Release