Summer Registration

Name of Summer Program Attendee *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Pronouns (select all that apply)

He/Him

She/Her

They/Them

Other

Phone

(###)

###

####

Photo consent given to Opal Family Services to take/post photos and/or videos of individual registered?

Yes

No

Please select the summer programming you would like to register for

Little Ones Play Group

Kids Club

Teen Group

Adult Day Program

Parent/Guardian #1

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone #1

(###)

###

####

Phone #2

(###)

###

####

Parent/Guardian #2

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone #1

(###)

###

####

Phone #2

(###)

###

####

Emergency Contact #1

First Name

Last Name

Phone #1

(###)

###

####

Phone #2

(###)

###

####

Emergency Contact #2

First Name

Last Name

Phone #1

(###)

###

####

Phone #2

(###)

###

####

Current Medical Information

Type 1 Diabetes

Type 2 Diabetes

Bleeding/Clotting

Cerebral Palsy

Heart Disease/Defect

Epilepsy

None

Other

Please check all applicable areas:

Asthma

Wheezing with breathing

Wheezing with exercise

Wheezing from environmental allergies

Does the individual registered have any dietary concerns?

Halal

Lactose-Intolerance

Vegetarian

Gluten-Intolerance

Celiac

None

Other

Upon agreement, Opal Family Services can provide monthly invoicing. Please select the appropriate option below:

Social Development has agreed to receive monthly invoicing

Jordan's Principle has agreed to receive monthly invoicing

Parent/Guardian has agreed to receive monthly invoicing

Other