Childrens Program Registration Form Please fill out this form to register for an upcoming retreat or program. Child's Name* First Last Parent/Guardian Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*HomeCellWork/Other Email* Medical ConcernsWhat, if any, medical concerns (gluten intolerant, allergies, etc.) would be important for the staff to know about your child?Consent for photos* Yes, I consent No, I do not consent I consent to photos of my child being included on The Center for Spirituality and Enrichment website and in the newsletter. No child's name will be published.Emergency Contact*In Case of Emergency Contact(s) (Name & Phone Number):Please identify child's transportation provider*Drop OffPick Up (Child will not be allowed to go with anyone else)Other Comments/Concerns Δ
