Registration

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The world has gone topsy-turvy! Everything is upside down and backwards, and it’s the perfect day to let your wild and wacky side shine. Come dressed in mismatched clothes, rock your craziest hair, and get ready to see the world from a whole new perspective. Let’s embrace the madness and have some fun!

Event:

Start Date/Time:

End Date/Time:

Fee per Student:

Room:

* - denotes required fields

Family Information

	First Name:*	Last Name: *
	Type*
	Home Phone:*	Cell #: Work #:
	Email:*	(Emails are kept confidential)

	Address: *
	City: *	State: * Zip: *
	Emergency Contact Info*

Students entered below will be added to your family's account

Add New Student #1:

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	Student's First Name: *	Last Name: *
	Student Gender: *	Birth Date: * (format=mm/dd/yyyy)
	School:	Grade Level:
	List any known allergies/allergic reactions::
	List any Medications::
	Primary Doctor's Name & Phone # & Date of Last Exam:*
	List any previous surgeries:
	List any previous broken bones:
	List any other health concerns:

Additional Information: