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Summer BLAST Program Registration 2026

PARTICIPANT AND CONTACT INFORMATION - Page 1 of 4

Please complete a registration form for each child who will be participating.

IMPORTANT NOTE: Participants should be able to manage their personal needs independently. If additional support is needed, a parent/guardian must provide a support person to attend.

*1.Which location are you registering for? (Choose One)(Required.)

Frackville

Mahanoy City

Minersville

Pottsville

Schuylkill Haven

Tamaqua

*2.Participant Information(Required.)

First and Last Name

Age

Last Grade Completed

School District

*3.Parent/Guardian Information(Required.)

First and Last Name

Address

Phone Number

Alternate Phone Number

Email Address

4.Additional Parent/Guardian Information

First and Last Name

Address

Phone Number

Alternate Phone Number

Email Address

*5.Who should we contact in case of an emergency?(Required.)

First and Last Name

Phone Number

Alternate Phone Number

*6.Does this participant have health insurance through either of the following? (Not a requirement to attend)(Required.)

Geisinger Health Plan Family

Geisinger Health Plan Kids

Neither of these

Unsure

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