Class 1: June 9-13 August 4-8
Student Information
Last First Birthday
Age/Grade: select 4yrs Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade School:
Home Address:
City: Zip:
Parent Name(s): Mobile Phone:
Mobile Phone:
Home Phone: Email:
Insurance Carrier: Member #:
Primary Care: Phone:
Food Allergies/Medical Restrictions or Special Needs:
My child may be released to the following adults who produce photo identification:
umc.org
