Name of Child *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Parent Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent Cell Phone

(###)

###

####

Parent Home Phone

(###)

###

####

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

The EYE Saturday Program provides a free pizza lunch for all participants! To avoid wasting food, please check the appropriate box below.

YES, my child will be eating a pizza lunch

My child will be bringing a bagged lunch

Photo Release Consent

I give consent for photos of my child taken at the EYE Saturday Program to give consent for photos of my child taken at the EYE Saturday Program to be used in the promotion of further elementary engineering programs in Saratoga Springs.

Yes, I give permission

No, I do not give permission