Pre-Teen Program (Grades 4-6)

 

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1. Child’s name or nickname (please indicate the name your child would like to have the librarian use when taking attendance)

Child’s name or nickname (please indicate the name your child would like to have the librarian use when taking attendance)

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2. Child's age

Child's age

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3. First and last name of Parent or Caregiver accompanying the child

First and last name of Parent or Caregiver accompanying the child

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4. Telephone

Telephone

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5. Telephone number of another parent/caregiver for emergencies

Telephone number of another parent/caregiver for emergencies

6. E-Mail Address (only if you prefer we contact you this way)

E-Mail Address (only if you prefer we contact you this way)

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7. Does your child have any health related problems or allergies?

Does your child have any health related problems or allergies?   Yes No

8. If you answered Yes to the previous questions, please explain:

If you answered Yes to the previous questions, please explain: