Pre Pesach Application

LTC

Apply Online

Please fill out all the required fields, and click Submit when you are done.

1. Child Information

Are you already a Glick Girl/Guy?

First Name

Last Name

School

Current Grade

Child #2 First Name

Child #2 Current Grade

Child #2 School

Child #3 First Name

Child #3 Current Grade

Child #3 School

Child #4 First Name

Child #4 Current Grade

Child #4 School

Allergy: Please list anything your child is allergic to. If your child owns an EpiPen, please state:

Does your child receive extra assitance in a school/camp setting? (This way we can ensure to provide properly for your child).

Note: Please don't register any child in a diaper for this program. Thank you!

2. Personal Information

Mother's Name

Mother's Cell

Father's Name

Father's Cell

Email Address

3. Pick your Days

Sunday is not included in this promotion. If you would like to register for Sunday, or for more day/children than allowed with this promotion, please register at Glickgirl.com. Thank you!

4. Submit

By registering your child in GlickGirl, you and any legal guardian of your child give permission for the staff at GlickGirl to deal with any medical emergencies and make any necessary medical decisions, and agree not to hold Glick Girl LLC liable for illness or injury. I agree to the terms and conditions as seen here.

Date

Electronic Signature

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