MPU Enrollment Form 2019-2020

If you are enrolling more than one daughter, please complete a separate form for each.

Question Title

* 1. Parent Name and Address

Parent First Name

Parent Last Name

Street Address

Town

State

Zip Code

Question Title

* 2. Parent's Primary Email Address

Question Title

* 3. Secondary Email Address (optional)

Question Title

* 4. Emergency Contact Number

Question Title

* 5. Secondary Emergency Contact Number (optional)

Question Title

* 6. Daughter's FIRST Name

Question Title

* 7. Daughter's LAST Name

Question Title

* 8. Daughter's Birthdate

Birthdate

Date

Question Title

* 9. Daughter's Grade as of September 2019

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Question Title

* 10. School Attending in September 2019

Question Title

* 11. Daughter's t-shirt size

Small (6-8)

Medium (10-12)

Large (14-16)

Extra Large

Question Title

* 12. Does your daughter have any allergies or special needs?

Yes

If Yes, please explain:

Question Title

* 13. Is your daughter in Girl Scouts?

Yes

Question Title

* 14. If yes, what Girl Scout Troop Number?

Question Title

* 15. How did you hear about the program? (select all that apply)

Friend (please provide name below for referral credit)

School flyer / communication

HamletHub

Ridgefield Press

Boys and Girls Club

Facebook

Flyer posted in town (if so, please specify place of business)

Other / Comments (indicate name of referral, and/or place of business you saw flyer posted):

Question Title

* 16. For the sessions held at the Ridgefield Library, does your daughter have your permission to leave the program room at the end of the session unescorted? (If no, she will need to wait until an approved adult signs her out.)

Comments: