Children’s Program Registration | Daniel Pierce Library

Child's Name*
First Last
Birthdate*
Date Format: MM slash DD slash YYYY
Age*
Email*
Phone*
Parent/Guardian Name*
First Last
Physical Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address
Street Address Address Line 2 City State ZIP Code

Complete only if different from physical address.
Emergency Contact Information
If parent cannot be contacted, who should be contacted in case of emergency?
Emergency Contact*
First Last
Emergency Contact Phone*
Program Registration
Please register for one program per child.
Mother Goose Time
12-23 Months (must be 12 months by 12/1/19)
Toddler Time
24-35 Months (must be 24 months by 12/1/19)
Story Hour
3, 4, & 5 Year Olds (must be 3 years by 12/1/19)
This program is open to Tri-Valley residents only.*
- I confirm that I am a resident of the Tri-Valley Central School District.
Weather Cancellations*
- I understand
When the Tri-Valley Central School District is closed or delayed due to inclement weather, ALL storytimes will be cancelled.
Name
This field is for validation purposes and should be left unchanged.

Emergency Contact Information