Child's Information

First Name *

Last Name *

Age *

Date of birth *

Address *

City *

State *

Zip code *

Phone *

Grade *

School Attended *

Is the child on any doctor restrictions or medications? (Type NONE if none exists) *

Allergic to anything? (Type NONE if none exists) *

Can he swim? *

Yes

No

Why is this child best fit for this program? *

Parents' Information

Mother

Mother's Full Name *

Mother's Phone Number *

Mother's Email *

Father

Father's Full Name *

Father's Phone Number *

Father's Email *

Child lives with: *

Mother

Father

Both

Other

By providing my phone number, I agree to receive text messages from the Hoodstock organization and its affliliates.

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