Pre-Registration FormPlease enable JavaScript in your browser to complete this form.Today's Date *1st AdultName *FirstLastGenderLadyGentDate of BirthEmail *AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCell PhoneDo you receive texts?YesNo2nd AdultName *FirstLastGenderLadyGentDate of BirthEmailCell PhoneDo 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 *FirstLastGenderGirlBoyDate 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?Is your child receiving accommodations or specially designed instruction through an IEP, a 504 Plan, or Title 1 services?YesNo2nd ChildNameFirstLastGenderGirlBoyDate 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?Is your child receiving accommodations or specially designed instruction through an IEP, a 504 Plan, or Title 1 services?YesNo3rd ChildNameFirstLastGenderGirlBoyDate 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?Is your child receiving accommodations or specially designed instruction through an IEP, a 504 Plan, or Title 1 services?YesNo4th ChildNameFirstLastGenderGirlBoyDate 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?Is your child receiving accommodations or specially designed instruction through an IEP, a 504 Plan, or Title 1 services?YesNo5th ChildNameFirstLastGenderGirlBoyDate 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?Is your child receiving accommodations or specially designed instruction through an IEP, a 504 Plan, or Title 1 services?YesNo6th ChildNameFirstLastGenderGirlBoyDate 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?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.NameSubmit
