Banana Splits Signup Form
(All Information is Confidential)
Dear Parents, please print and fill out this form to submit as hard copy. Or you can use an email form here.
__________________________
Child’s Name: _____________________________________Age: ___Grade: ___DOB: ___/___/___
Address:
________________________________________________________________________
Street Apt. #
Town
Zip Code
Home phone: _____________________Work:____________________Cell:____________________
Email Address: ____________________________________________________________________
School attended: ___________________________________________________________________
Custodial Parent’s Name: ____________________________________________________________
___Separated from child’s other parent How long? _______
___Divorced from child’s other parent How long? _______
With whom does your child live? ___________________________________
In case of illness or emergency during group time, whom should we call if we cannot reach you?
Name: ___________________________________________Phone: ________________________
Relationship with your child: _____________________________________________________
Is there any additional information that would help us to support your child during group time? _________________________________________________________________________________
_______________________________________________________________________________________
Today’s date: ___/___/___
Send Form to Kevin Lee, Youth Advocate, Town
Hall, 400 Slocum Road, Dartmouth, MA 02747
You can also drop the form at my office, room 118, Town Hall. Thanks!