PD Day Camp (ages 5-7)

Child's First Name: *

Child's Last Name: *

Child's Age: *

Child's Pronouns (e.g. she, he, they): * She/Her He/Him They/Them Other

Parent/Guardian Full Name: *

Email: *

Phone Number: *

Full Name of Emergency Contact: *

Emergency Contact's Phone Number: *

Names of Other Adults Approved for Pickup: *

Special Considerations & Allergies: