Hadley Park After School Registration

Center Requested

Center requested

Participant Information

Participant name

Gender

Male

Female

Do not wish to disclose

Birthdate

Grade Entering in the Fall

Address

City

State

Zip

Phone number

What school will your child be attending in the fall?

Parent/Guardian Information

Parent/Guardian name

Email

Phone number

City

State

Emergency Contact Information

Emergency contact name

Address

City

State

ZIP code

Phone number

Relationship

Health Information

Does this child have any allergies, medical, behavioral or emotional problems that staff should be aware of?

Allergy, medical, behavioral or emotional problem?

Yes

No

If yes, please explain

Does your child have permission to participate in swimming activities?

Swimming permission?

Yes

No