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Family Registration
Family Registration
Parent/Guardian
First Name
*
Last Name
*
Email
*
Parent Phone
*
Birth Date
*
MM/DD/YYYY
Gender
*
Female
Male
Are you of Hispanic, Latino, or Spanish origin?
*
Yes
No
Prefer not to say
What is your race? (Select all that apply)
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to say
Other
Other
Address
*
Address
Address
Address
City
City
State
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Zip Code
Office Use
Counselor/Group Name
*
Start Date
*
End Date
Children
First Name
*
Last Name
*
Birth Date
*
Gender
*
Female
Male
Allergies or Special Needs
plus
Add another child
minus
Remove this child
Emergency Contacts
Name
*
Name
First Name
First Name
Last Name
Last Name
Emergency Contact Phone
*
Relationship to child
*
Mother
Father
Grandmother
Grandfather
Aunt
Uncle
Cousin
Brother
Sister
Guardian
Other
Relationship to child
Name
Name
First Name
First Name
Last Name
Last Name
Emergency Contact Phone
Relationship to child
Mother
Father
Grandmother
Grandfather
Aunt
Uncle
Cousin
Brother
Sister
Guardian
If you are human, leave this field blank.
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