On Belay Session Date:

Child's Name:

Your Name:

Relation to child:

Child's age as of program:

Mailing Address:

Email:

Phone:

Has your child attended an On Belay program before?

If your child has a sibling attending, would they prefer to be separate or together during the program?

*Please note: On Belay is a recreational program designed to provide all participants with a sense of security, comfort and most of all fun. If for any reason your child is not able to respect other participants, facilitators and the goals of the program; On Belay staff will call you and ask you come pick up your child.