Child 1 Information:
First Name
*
Gender
*
Male
Female
Date of Birth
*
mm/dd/yyyy
School Attending
*
N/A (Pre-School only)
Hornet's Nest Elementary School
Long Creek Elementary School
Statesville Road Elementary School
Barnette Elementary School
Winding Springs Elementary School
Blythe Elementary School
Bradley Middle School
Lincoln Charter School
Mountain Island Lake Academy
Mountain Island Charter School
Mountain Island Day School
Oakdale Elementary School
Paw Creek Elementary School
River Oaks Academy
White Water Academy
White Water Middle School
Coulwood Middle School
Last Name
*
Age
*
Grade
*
Pre-K
K
1
2
3
4
5
6
7
Signing up for:
*
Pre-School
Before School
After School
Before and After-School
Summer Camp
Drop-in
Child 2 Information:
First Name
*
Gender
*
Male
Female
Date of Birth
*
mm/dd/yyyy
School Attending
*
N/A (Pre-School only)
Hornet's Nest Elementary School
Long Creek Elementary School
Statesville Road Elementary School
Barnette Elementary School
Winding Springs Elementary School
Blythe Elementary School
Bradley Middle School
Lincoln Charter School
Mountain Island Lake Academy
Mountain Island Charter School
Mountain Island Day School
Oakdale Elementary School
Paw Creek Elementary School
River Oaks Academy
White Water Academy
White Water Middle School
Coulwood Middle School
Last Name
*
Age
*
Grade
*
Pre-K
K
1
2
3
4
5
6
7
Signing up for:
*
Pre-School
Before School
After School
Before and After-School
Summer Camp
Drop-in
Child 3 Information:
First Name
*
Gender
*
Male
Female
Date of Birth
*
mm/dd/yyyy
School Attending
*
N/A (Pre-School only)
Hornet's Nest Elementary School
Long Creek Elementary School
Statesville Road Elementary School
Barnette Elementary School
Winding Springs Elementary School
Blythe Elementary School
Bradley Middle School
Lincoln Charter School
Mountain Island Lake Academy
Mountain Island Charter School
Mountain Island Day School
Oakdale Elementary School
Paw Creek Elementary School
River Oaks Academy
White Water Academy
White Water Middle School
Coulwood Middle School
Last Name
*
Age
*
Grade
*
Pre-K
K
1
2
3
4
5
6
7
Signing up for:
*
Pre-School
Before School
After School
Before and After-School
Summer Camp
Drop-in
Parent Information:
Parent Name
*
City
*
Zip Code
*
Cell Phone
Mother's Work Phone
*
Father's Work Phone
*
Address
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Phone Number
*
E-mail
*
Mother's Place of Employment
*
Father's Place of Employment
*
Emergency Contact
(other than the parent)
Full Name
*
Phone
*
Check this box to accept these
terms and conditions
.
Special Instructions*
Please place in this box any special instructions for your child including: allergies, medications, special needs, etc. If signing up for Summer Camp, please place in this box also the weeks you are signing up for.
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