REGISTRATION Program Registration What program/time are you registering for? * Playology: 9:00 to 10:00 Playology: 10:30 to 11:30 Le Savoir: 4:00 to 5:00 Child Information Name First Name Last Name Birthdate: MM DD YYYY Gender Male Female Other Age (in Years and Months): Address Address 1 Address 2 City State/Province Zip/Postal Code Country Please list any allergies or dietary restrictions: Has your child previously been diagnosed with any speech-language, motor, or other developmental delays? Yes No If yes, please describe: Parent/Guardian Information Parent/Guardian Name: First Name Last Name Relationship to child: Mother Father Other* *If other, please specify: Address: Address 1 Address 2 City State/Province Zip/Postal Code Country Phone: (###) ### #### Email: Second Parent/ Guardian Name (if applicable): Second Parent/ Guardian Name: First Name Last Name Relationship to child: Mother Father Other* *If other, please specify: Address (if different from first listed parent/guardian): Address 1 Address 2 City State/Province Zip/Postal Code Country Phone: (###) ### #### Email: Emergency Contact (if the identified parent/guardian(s) cannot be reached): Name: First Name Last Name Relationship to child: Phone: (###) ### #### How did you hear about our programs? Flyer Social Media Through a friend/word of mouth Other* *If other, please specify: Would you be interested in hearing about future day camps/programming? Yes No If yes, please provide your email address: Thank you for registering for Playology! Once your request for registration is received, you will be sent a confirmation email and payment information.
