Hadley Park Afterschool Registration

Required fields

Center Requested

Center requested

Select... Hadley

Participant Information

Participant name

Gender

Male
Female
Do not wish to disclose

Date of birth

Grade Entering in the Fall

Select... Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th 9th

Current address

City

State

Select... AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip code

Phone number

What school will your child be attending in the fall?

Parent/Guardian Information

Parent/Guardian name

Email

 

Phone number

Work phone number

City

State

Select... AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Emergency Contact Information

Emergency contact name

Address

City

State

Select... AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip code

Phone number

Relationship

Select... Mother Father Grandparent Uncle Aunt Other

Health Information

Does this child have any allergies, medical, behavioral or emotional problems that staff should be aware of?

Allergy, medical, behavioral or emotional problem?

Yes
No

If yes, please explain

Does your child have permission to participate in swimming activities?

Swimming permission?

Yes
No