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* 1. Your Name

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* 2. Mailing Address

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* 3. Email Address (please provide the email address it will be easiest to reach you at over the summer)

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* 4. Phone numbers you can be reached at

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* 5. How old will you be in June 2017?

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* 6. Date of Birth

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* 7. What school will you attend in August 2017?

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* 8. Parent/Guardian's Name(s)

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* 9. Parent/Guardian's Phone

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* 10. Parent/Guardian's Email

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* 11. Emergency Contact information

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* 12. Primary doctor

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* 13. Please list any medical conditions or allergies that might impact your participation in daily activities working around children or animals:

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