Pioneer Club Registration form

Submitted by Artlady on Wed, 01/30/2008 - 2:26pm.

Registration is recommended. This ensures that we will have materials for your child. When you drop your child off the first day, you will need to sign an emergency release form. All information will be kept confidential. Thank you for your cooperation. We look forward to meeting your child March 2nd!

Date: *

month/day/year

child name: *

****last, first, middle initial

grade: *

current school grade

birthdate: *

month/day/year

address: *

street PO Box Apt.#

city, state, zip: *

city state zip

email:

home phone: *

mother's name and cell phone:

mother or guardian name and cell phone

father's name and cell phone:

father or guardian and cell phone number

allergies and special needs: *

describe any allergies and needs your child may have