Name of Child *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent Cell Phone *

(###)

###

####

Parent Home Phone *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

The EYE Saturday Program provides a free pizza lunch for all participants! To avoid wasting food, please check the appropriate box below. *

YES, my child will be eating a pizza lunch.

My child will be bringing a bagged lunch.

Financial Assistance *

If paying for EYE is a hardship, please check the appropriate box below, and we will waive the entrance fee.

Yes, for my child to participate, financial assistance is necessary.

No, financial assistance is not necessary.

Photo Consent *

By attending this event, I understand that my child's photo may be taken and could be used in the promotion of future events.