Child's Name

Mailing Address

City/State/Zip

Home Phone    Cell Phone

Email Address (optional)

Date of Birth Last Grade Completed

Emergency Contact Emergency Phone

Parent/Guardian Name

Allergies/Medical Concerns

Home Church

Name of Friend You'd Like to Be With

Other Pertinent Info or Questions

 Parent permission slips will be available on site for specific activities requiring permission.

You'll be returned to Charter Oak's Home Page after you submit.