Monkey House Carbondale Youth Program Questionnaire

The following information must be completed by a parent/guardian for anyone under age 18 who will be participating in one or more of Monkey House Carbondale's youth programs or classes. 

Participant's Name *
Participant's Name
Participant's Date of Birth *
Participant's Date of Birth
Phone *
Emergency Contact Phone: *
Emergency Contact Phone:
Emergency Contact Alternate Phone (Optional)
Emergency Contact Alternate Phone (Optional)
We will not allow any child to leave the premise in the custody of anyone not listed. If someone not listed here will be picking up/dropping off your child, please let us know in advance.