2016-2017 Clubhouse Participant Emergency Form

A Participant Emergency Form must be completed for each individual child prior to the start of Clubhouse. We can't take a child into our care if this form has not been completed. This form most be completed in its entirety or you may have to restart it. The form will take approximately 15 minutes to complete. Please make sure you have the date of your child's last tetanus shot and physician information along with the contact information for persons allowed to pick your child up or contacted in case of emergency.

Guardians listed below will be used as the first line of emergency contact as well as authorized to pick up the child from clubhouse.

Participant Information:

Child's First Name *This question is required.

Child's Last Name *This question is required.

Child's Birthday (MM/DD/YYYY) *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Primary Guardian's First Name *This question is required.

Primary Guardian's Last Name *This question is required.

Secondary Guardian's First Name

Secondary Guardian's Last Name

Address *This question is required.

City *This question is required.

State *This question is required.

Postal Code *This question is required. This question requires a valid number format.

Home Phone

Primary Guardian Cell Phone

Primary Guardian E-mail *This question is required.

Secondary Guardian Cell Phone

Secondary Guardian E-Mail