Pre-Registration FormPlease enable JavaScript in your browser to complete this form.Today's Date *1st AdultName *FirstLastGender *LadyGentDate of Birth *Email *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCell Phone *Do you receive texts? *YesNo2nd Adult ?YesNoName *FirstLastGender *LadyGentDate of Birth *Email *Cell Phone *Do you receive texts? *YesNoIf someone other than 1st Adult or 2nd Adult listed above will be picking up your child please list their name below.1st ChildName *FirstLastGender *GirlBoyDate of Birth *Grade (if school age what grade are they in?) *Nursery (6 wks - 2 yrs)Pre-School (2 - 4 yrs)Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeAny allergies or special conditions? (NA for none) *Is your child receiving accommodations or specially designed instruction through an IEP, a 504 Plan, or Title 1 services? *YesNo2nd Child?YesNoName *FirstLastGender *GirlBoyDate of Birth* *Grade (if school age what grade are they in?) *Nursery (6 wks - 2 yrs)Pre-School (2 - 4 yrs)Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeAny allergies or special conditions? (NA for None) *Is your child receiving accommodations or specially designed instruction through an IEP, a 504 Plan, or Title 1 services? *YesNo3rd Child ?YesNoName *FirstLastGender *GirlBoyDate of Birth* *Grade (if school age what grade are they in?) *Nursery (6 wks - 2 yrs)Pre-School (2 - 4 yrs)Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeAny allergies or special conditions? (Na for None) *Is your child receiving accommodations or specially designed instruction through an IEP, a 504 Plan, or Title 1 services? *YesNo4rth Child ? YesNoName *FirstLastGender *GirlBoyDate of Birth* *Grade (if school age what grade are they in?) *Nursery (6 wks - 2 yrs)Pre-School (2 - 4 yrs)Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeAny allergies or special conditions? (NA for None) *Is your child receiving accommodations or specially designed instruction through an IEP, a 504 Plan, or Title 1 services? *YesNo5th Child ? YesNoName *FirstLastGender *GirlBoyDate of Birth* *Grade (if school age what grade are they in?) *Nursery (6 wks - 2 yrs)Pre-School (2 - 4 yrs)Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeAny allergies or special conditions? (NA for none) *Is your child receiving accommodations or specially designed instruction through an IEP, a 504 Plan, or Title 1 services? *YesNo6th Child ?YesNoName *FirstLastGender *GirlBoyDate of Birth* *Grade (if school age what grade are they in?) *Nursery (6 wks - 2 yrs)Pre-School (2 - 4 yrs)Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeAny allergies or special conditions? (NA for none) *Is your child receiving accommodations or specially designed instruction through an IEP, a 504 Plan, or Title 1 services? *YesNoBy registering my child for Summit Kids, I authorize that my child's image may be photographed, filmed, and be in video, print, and web presentations. By giving my email address, I understand that I will be added to Clear Mountain's mailing list. Clear Mountain will not give your personal information to any 3rd parties.WebsiteSubmit
