Name of Child *

First Name

Last Name

Child's birthdate *

MM

DD

YYYY

Which Coulee Critters program would you like your child to attend? *

2024 Summer Program (Jul 9 - Aug 29) - 8 weeks

Which day(s) of the week would you like your child to attend? *

Please check off which day(s) you would like for your child to attend. The morning program runs from 9 am to 12 pm. Afternoon program runs from 1 pm to 4 pm. Classes are subject to change dependent on enrollment.

Tuesday AM - $280 (Full/waitlisting)

Wednesday AM - $280 (Full/waitlisting)

Thursday AM - $280 (Full/waitlisting)

Name of Parent/Guardian *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Emergency Contact *

First Name

Last Name

Primary Phone *

(###)

###

####

Alternate Phone *

(###)

###

####

Does your child have any allergies? *

Yes

No

Is an Epi-pen required?

*If anaphylactic, your child MUST bring a minimum of 2 Epi-pens.

Yes

No