PUDDLESTOMPERS  Nature Exploration

TM

Parent Name(s): _____________________________________     ____________________________________________
Child Name: ______________________________________________   Child Date of Birth: ___________________
2nd Child Name:  ____________________________________   2nd Child Date of Birth: _______________________
Caregiver’s Name: ________________________________________________________________________________
(if applicable)
Allergies/Medical conditions:  ________________________________________________________________________

Address: _________________________________________________________________________________________
            __________________________________________________________________________________________
Email address: ____________________________________________________________________________________
Home Phone:__________________________________   Cell Phone: ________________________________________
Emergency Contact and Phone: ______________________________________________________________________
How did you hear about us? _________________________________________________________________________
__________________________________________________________________________________________________

Vacation Program(s):                  

Columbus Day. 10/10: ____                       Veterams Day, 11/11: ____

Number of Children:_________________       Tuition: ___________________               Total:_____________________  

Vacation Program Registration
Complete this form and the release form, then print and mail with a check payable to PUDDLESTOMPERS to:

PUDDLESTOMPERS
47A River Street
Wellesley, MA 02481