First Sweep Summer Program Registration

Please fill out the form below to request your registration information.
( * ) denotes a required field.



Participant
First Name:
Last Name:
Sex:  Male  Female
Age: DOB: 
Parent/Guardian 1
* First Name:
* Last Name:
*E-mail:
Phone Number:
Address:
City:
State/Province:    Zip:  
Employer:
Employer Phone:
Parent/Guardian 2
First Name:
Last Name:
E-mail:
Phone Number:
Address:
City:
State/Province:    Zip:  
Employer:
Employer Phone:
Additional Information
Emergency Contact  
First Name:
Last Name:
Phone Number:

Is there anything we need to better serve your child/participant?
(Example: special physical or emotional needs, behavioral issues,
health concerns or allergies, etc.)
Comments:
I have read and agreed to the waiver for this child/participant.
   
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