Please provide the following contact information:

Childs Name
Address
Address (cont.)
City
Date of Birth
Postal Code
Home Phone
E-mail

Are there any medical conditions, allergies or medication we need to be aware of:

Select any of the following options that apply:

Monday 4 to 5pm      	Monday 5 to 6pm      

Tuesday 4 to 5pm     	Tuesday 5 to 6pm   		Tuesday 6 to 8pm     

Wednesday 4 to 5pm   	Wednesday 5 to 6pm  

Thursday 4 to 5pm    	Thursday 5 to 6pm    	Thursday 6 to 8pm   

Friday 4 to 5pm      		Friday 5 to 6pm    
Saturday 10 to 11am  	Saturday 11 to 1pm