Student/Camper Profile - Laughing Coyote Project

Child’s Name *

Child’s Date of Birth *

Child’s Age *

Program Enrolling

Preferred days (Not guaranteed)

Full Name *

Relationship to Child *

Email *

Phone *

Full Name

Relationship to Child

Email

Phone

Full Name *

Relationship to Child *

Primary Phone *

Secondary Phone

Full Name

Relationship to Child

Primary Phone

Secondary Phone

Does your child have any medical conditions that we should be aware of? *

Yes

No

If yes, please explain: *

Does your child have any allergies (medications, insect, foods, plants, and/or others) that we should be aware of? *

Yes

No

If yes, please explain: *