Parent/Guardian Name *

First Name

Last Name

Are you the child's Emergency Contact *

Yes

No

Parent Phone Number *

(###)

###

####

Child's Name *

First Name

Last Name

Address *

You must provide the address for the child's main residency for emergency purposes.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does your child have any medical conditions or allergies we need to be aware of? *

No

Yes (Please list below)

Please select a date you wish to have your lessons. *

THURSDAYS: 4-6PM - Ontelaunee Lake, Leesport PA SATURDAYS: 5-7PM - Stonecliff Rec Area, Reading PA SUNDAYS: 5-7PM - Stonecliff Rec Area, Reading PA

MM

DD

YYYY

You may select more than one date but do not have to

MM

DD

YYYY

Will you be staying with your child? *

ONLY for children 12 and up

Yes, I am staying for the session

No, my child is 12+ I will not be supervising the lesson

By selecting this you agree to Block 2 Bank Fishing Rules & Policies. You agree that all the information you submit is accurate and can be used for our database in order to connect with you and your child for your sessions and future events. You agree to providing anything your child needs for medical safety such as prescription medication, sunscreen, bug spray, etc. You agree to providing transportation for your child to and from the session unless otherwise arranged with the organization. You agree to arrive on time for your scheduled session unless you've communicated with the organization in advance. *

I agree