author russel bernstein | bully talks
KING O O C , S T F A ARTS & CINRG & MORE! SWIMM
AUTHOR RUSSEL BERNSTEIN | BULLY TALKS TUESDAY, NOV. 3 • 9AM - 4PM
$47 After School/Kids Klub • $57 Member • $65 Nonmember Registration deadline: Oct. 29, 2015. Late registrations subject to a $10 late fee. (Please Print)
Child’s Name:___________________________________________________Grade:_________________________ Parent’s Name:________________________________________________________________________________ Address:______________________________________________City:_________________State:___ Zip:________ Home #:_________________________Work #:_________________________Cell #:_________________________ Email:________________________Special Allergies___________________________________________________ Emergency Contact:______________________________________Emergency Phone:_______________________ Check One: IMPORTANT NOTICE: KidsKlub/AfterSchool • All children must have a • Please send your child(ren) with Member physical and paperwork on file. If you appropriate attire: sneakers, bathing suit, Non-Member need forms, contact Kari (203) 387-2522 x236 towel, and a dairy lunch. NO MEAT OR or [email protected]
PEANUT PRODUCTS.
METHOD OF PAYMENT VISA Mastercard
American Express
EXTENDED CARE OPTIONS Discover
Cash Check Enclosed Credit Card #:_________________________________Exp:_______ CVV:______Signature:______________________________________
NO REFUNDS Please check all that apply: WITHOUT $15 m/nm | $10 AfterSchool/Kids Klub families 24 HOUR Morning Care 7-9 AM NOTICE Evening Care 4-6 PM
360 Amity Road, Woodbridge, CT • 203.387.2522 • www.jccnh.org
AUTHOR RUSSEL BERNSTEIN | BULLY TALKS TUESDAY, NOV. 3 • 9AM - 4PM
$47 After School/Kids Klub • $57 Member • $65 Nonmember Registration deadline: Oct. 29, 2015. Late registrations subject to a $10 late fee. (Please Print)
Child’s Name:___________________________________________________Grade:_________________________ Parent’s Name:________________________________________________________________________________ Address:______________________________________________City:_________________State:___ Zip:________ Home #:_________________________Work #:_________________________Cell #:_________________________ Email:________________________Special Allergies___________________________________________________ Emergency Contact:______________________________________Emergency Phone:_______________________ Check One: IMPORTANT NOTICE: KidsKlub/AfterSchool • All children must have a • Please send your child(ren) with Member physical and paperwork on file. If you appropriate attire: sneakers, bathing suit, Non-Member need forms, contact Kari (203) 387-2522 x236 towel, and a dairy lunch. NO MEAT OR or [email protected]
PEANUT PRODUCTS.
METHOD OF PAYMENT VISA Mastercard
American Express
EXTENDED CARE OPTIONS Discover
Cash Check Enclosed Credit Card #:_________________________________Exp:_______ CVV:______Signature:______________________________________
NO REFUNDS Please check all that apply: WITHOUT $15 m/nm | $10 AfterSchool/Kids Klub families 24 HOUR Morning Care 7-9 AM NOTICE Evening Care 4-6 PM
360 Amity Road, Woodbridge, CT • 203.387.2522 • www.jccnh.org
