Arts & Athletics Application

Arts & Athletics Application
Student's First Name
Student's Last Name
Student's Date of Birth
Parent's First Name
Parent's Last Name
Mailing Address
Mailing Address (Continued)
Zip Code
Preferred Phone No.
Alternate Phone No.

Emergency Contact (other than parents; please include name and phone number)

Select the group you would like to register for:
Leisure + Snack + Track & Field (3:15-5:00)
Leisure + Snack + Art Studio (3:15-5:00)
Leisure + Snack + Performing Arts (3:15-5:00)
 Track & Field ONLY (4:00-5:00)
Art Studio ONLY (4:00-5:00)
Performing Arts ONLY (4:00-5:00)
Who will be picking up your child after each practice? (Please note that unless otherwise indicated, we will not send the student home with anyone else)
Phone Number for Person Picking Up Student:
I understand that I must make payment (check or credit card) to Ivymount Outreach Programs for the registration to be complete.

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