Child's First Name:  * Child's Last Name:  * Parent/Guardian First Name:  * Parent/Guardian Last Name:  * Address: City: State: Zip Code: Phone 1:  * Phone 2: E-Mail Address:

Emergency Contact:  * Emergency Contact Phone: I give permission for the following people to pick up my child: Grade in School: Pre-KKindergartenFirstSecondThirdFourthFifth T-Shirt Size: Youth XSYouth SmallYouth MediumYouth LargeYouth Extra LargeAdult SmallAdult MediumAdult LargeStill have shirt Is your child allergic to peanuts? YesNo List any other allergies your child has:   I give permission to use my child's photo in materials or on the web (the child will not be identified): YesNo   Would you be interested in helping provide a meal for our Can Do Kids leaders? YesNo Comments: Security code:   * Do not enter anything in this field: