CLUBBER'S NAME

GRADE AS OF 2009-2010 SCHOOL YEAR:

PARENT'S NAME:

ADDRESS:

CITY:

STATE:

ZIP CODE:

EMAIL ADDRESS:

PHONE NUMBER:

CELL PHONE NUMBER:

EMERGENCY CONTACT PERSON:

EMERGENCY CONTACT PHONE NUMBER:

BIRTHDAY

ALLERGIES (food or insect):

PLEASE INDICATE IF THERE ARE ANY PERSONS NOT ALLOWED TO PICK UP YOUR CHILD: