Hinesburg Spring 2025 Registration — Olivia and Leslie Foundation

Child's Name

First Name

Last Name

Parent's Name

First Name

Last Name

Phone

(###)

###

####

Mailing Address

Email

Grade Level

Session

Emergency Contact

Name Phone Number Relationship to child

Pickup Information

Please list individuals authorized to pick up your child.

Health Information

Does your child have any allergies or other health concerns we should be aware of?

Media Release

Allow photos of my child to be used for program promotion

Yes

No

Program Policies

Attendance: Students are expected to attend all sessions. Please notify us in advance if your child will be absent.
Behavior: Positive and respectful behavior is expected from all participants. Disruptive behavior may result in removal from the program.
Pickup Policy: Children must be picked up promptly at 4:30 PM. Late pickups may incur additional fees.

Consent and Release

By registering below, I agree to:

Allow my child to participate in the Play Pattern Afterschool Program.
Permit the program to seek emergency medical treatment if necessary.
Release the program from liability for any injuries or accidents that occur during the program hours.