Summer Program Registration

Child Name *

First

Last

Child Date of Birth *

Child Age *

Parent/Guardian *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Dr. Name *

Doctor Phone

Emergency Contact *

NAME and RELATIONSHIP

Emergency Contact Phone *

Available During the Day

Allergies *

Attire and Belongings: All children should be prepared with long pants, a boot with a heel, a lunch, and water bottle. Children are welcome to bring sneakers. A bathing suit and towel is suggested for hot days when we play water games. Please label all belongings.

I would like to drop off at 8a for $10/day

Yes
No

In the event that I/we are unavailable for the purpose of providing parental consent, I/we hereby authorize a qualified emergency medical technician, physician, or hospital emergency room, as selected by the staff of Red Skye Foundation, to provide such hospital care including routine diagnostic procedures and medical treatment to my child. I understand that the consent and authorization herein granted does not include major surgical procedures.

Parent/Guardian Signature *

Please Print Your Name

How would you like to pay?

Pay in Full ($325 per week)
Make a Deposit of $100

Form of Payment

Cash or Check
Credit Card

Please fill in your card number we will put the charge through.

Credit Card Number

Card Number no dashes

Expiration Date

Number only-no backslash

Security Code

Cardholder Name

Name

Summer Program Registration

110 Hatfield Hill Rd. Bethany, CT

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