Choose one of the following options: *

Kid Klick

Link Up

Other

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Prefer Not to Say

Other

Name *

First Name

Last Name

Phone: Include text number if not the same *

(###)

###

####

Address *

Include Unit #

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does your child have any allergies or medical conditions? *

Yes

No

Is your child prescribed an Anaphylactic / Epinephrine Auto-Injector (e.g., EpiPen)? *

Yes

No

I authorize program staff to obtain medical treatment for my child in case of emergency.

Yes

No

Name of emergency contact person *

First Name

Last Name

Phone of contact person *

(###)

###

####

Address of emergency contact *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name *

First Name

Last Name

Name *

First Name

Last Name

Is child allowed to leave program to walk home alone?

Yes

No

Permissions and Consents: Photo Release *

Yes, I give consent

No, I do not give consent

Select one of the filling options:

Participant

Volunteer