Please provide the following contact information for the person attending:

First Name
Last Name
Middle Initial
Date of Birth
Sex	Male Female
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Parent Name
Parent Work Phone
Home Phone
Parent E-mail

Choose one of the following options:

3 days a week
5 days a week

Choose one of the following options:

8 WEEKS (JUNE 22nd THRU AUGUST14TH)
4 WEEKS (JUNE 22nd THRU JULY 17TH)
4 WEEKS (JULY 20TH THRU AUGUST14TH)

Select any of the following options that apply:

INSURANCE                                               

COUNTY WAIVER (EXCEPT WAUKESHA COUNTY)                        
COUNTY FAMILY SUPPORT            

ESY FOR THOSE WHO ARE ALREADY QUALIFIED THROUGH THEIR SCHOOL DISTRICT                       
PRIVATE PAYMENT