Parent Night Out & Camps -

Student Name *

First

Last

Date Of Birth *

Incoming Grade Level *

Are you a Galloway Student? If not, what school do you attend? *

Mother's Name *

First

Last

Mother's Cell Phone *

Mother's Email *

Father's Name *

First

Last

Father's Cell Phone *

Father's Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact #1 *

First

Last

Emergency Contact #1 Relationship *

Emergency Contact #1 Phone *

Emergency Contact #2

First

Last

Emergency Contact #2 Relationship

Emergency Contact #2 Phone

Physician's Name *

First

Last

Physician's Phone *

Preferred Hospital

Medications

Allergies

Summer Camp (No Aftercare)

Summer Camp (With Aftercare)

Is this your 2nd or 3rd student enrolled? *

There is a 15% sibling rebate which will be returned via PayPal within 10 business days.

Total

$ 0.00

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