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"Give Me A Break" Child Information

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Please fill in the information below. Thank you.

How many children will you be bringing?*
Parent/Guardian Name *
First Name
Middle
Last Name
Parent/Guardian Name
First Name
Middle
Last Name
Address *
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Phone Number*
Emergency Phone Number*
Email Address*
Child 1 Name
First Name
Middle
Last Name
Gender
Age:
This Child is
Please explain any special needs, allergies, or diagnosis you wish our volunteers to be aware of, and how we can accommodate your child's unique needs.
Pajama Size child 1
Child 2 Name
First Name
Middle
Last Name
Gender
Age
The child is
Please explain any special needs, allergies, or diagnosis you wish our volunteers to be aware of, and how we can accommodate your child's unique needs.
Pajama Size child 2
Child 3
First Name
Middle
Last Name
Gender
Age
The child is
Please explain any special needs, allergies, or diagnosis you wish our volunteers to be aware of, and how we can accommodate your child's unique needs.
Pajama Size child 3
Child 4
First Name
Middle
Last Name
Gender
Age
The child is
Please explain any special needs, allergies, or diagnosis you wish our volunteers to be aware of, and how we can accommodate your child's unique needs.
Pajama Size child 4
Child 5
First Name
Middle
Last Name
Gender
Age
The child is
Please explain any special needs, allergies, or diagnosis you wish our volunteers to be aware of, and how we can accommodate your child's unique needs.
Pajama Size child 5
Child 6
First Name
Middle
Last Name
Gender
Age
The child is
Please explain any special needs, allergies, or diagnosis you wish our volunteers to be aware of, and how we can accommodate your child's unique needs.
Pajama Size child 6
*