Attendee EnrollmentChild's Full Name* First Last Age at Time of Session*Select One891011121314Please note that sessions are age specific (8-11 and 12-14). Only the age-appropriate session options will appear based on the answer you select here.Date of Birth* MM DD YYYY Gender*MaleFemaleFirst year attending Dog Days of Summer?*Yes, first time attending DDS.No, child has attended DDS in the past.Parent/Guardian Contact InformationName of Parent/Legal Guardian* First Last Parent or Legal Guardian*ParentLegal GuardianMailing Address* Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Daytime Phone*Phone Type*HomeCellWorkOtherParent/Guardian's Email* Enter Email Confirm Email Email Type*PersonalWorkSession SelectionOnly the age-appropriate sessions will be listed based on the "Age at Time of Session" answer you selected above. In the off chance that a session is overbooked or cancelled, we ask that you make two selections indicating your first and second session preference. Weeklong, Half-Day Sessions, Monday thru Friday, 8am-12pm OR 12:30-4:30pm. (Child enrollment is limited to one session per program season.)Session Selection - Ages 8-11 ONLY (First Choice)*June 22 – June 26 AM: Ages 8-11 (1st Choice)June 22 – June 26 PM: Ages 8-11 (1st Choice)July 6 – July 10 AM: Ages 8-11 (1st Choice)July 13 – July 17 PM: Ages 8-11 (1st Choice)July 20 – July 24 AM: Ages 8-11 (1st Choice)July 20 – July 24 PM: Ages 8-11 (1st Choice)July 27 – July 31 AM: Ages 8-11 (1st Choice)July 27 – July 31 PM: Ages 8-11 (1st Choice)Session Selection - Ages 8-11 ONLY (Second Choice)*June 22 – June 26 AM: Ages 8-11 (2nd Choice)June 22 – June 26 PM: Ages 8-11 (2nd Choice)July 6 – July 10 AM: Ages 8-11 (2nd Choice)July 13 – July 17 PM: Ages 8-11 (2nd Choice)July 20 – July 24 AM: Ages 8-11 (2nd Choice)July 20 – July 24 PM: Ages 8-11 (2nd Choice)July 27 – July 31 AM: Ages 8-11 (2nd Choice)July 27 – July 31 PM: Ages 8-11 (2nd Choice)Session Selection - Ages 12-14 ONLY (First Choice)*July 6 – July 10 PM: Ages 12-14 (1st Choice)July 13 – July 17 AM: Ages 12-14 (1st Choice)Session Selection - Ages 12-14 ONLY (Second Choice)*July 6 – July 10 PM: Ages 12-14 (2nd Choice)July 13 – July 17 AM: Ages 12-14 (2nd Choice)Emergency/Medical InformationEmergency Contact Name* First Last Emergency Contact Relationship to Child*Emergency Contact Daytime Phone*Primary Care Physician Name*Primary Care Physician Daytime Phone*Insurance Carrier*Insurance Member ID Number*Preferred Hospital (Full Name)*Does your child have any ALLERGIES?*No AllergiesYes, see info below for AllergiesIf "YES" to ALLERGIES, please list ALL allergies individually along with their respective: severity, participation limitations, medication/inhaler/Epi‐ pen needed on hand. FIdelco has two Ambassador cats on campus; children may be exposed to their dander at some point throughout the program.*Does your child have any LEARNING DISABILITIES?*No Learning DisabilitiesYes, see info below for Learning DisabilitiesIf "YES" to LEARNING DISABILITIES, please list any learning disabilities (ADHD, Autism Spectrum, Anxiety, Dyslexia, Language Processing, Non‐Verbal, Memory, etc.) along with the description of severity or special needs (high‐functioning, no additional staff required, etc.)*Does your child have any OTHER MEDICAL ISSUES?*No Other Medical IssuesYes, see info below for Other Medical IssuesIf "YES" to OTHER MEDICAL ISSUES, please list any Visual/Hearing Impairments and/or Mobility Limitations along with their respective: severity, participation limitations, medications needed on hand.*Accommodations: Please check all that apply* No accommodations need to be made. Parent/Guardian will be joining the child during each session. The child will be accompanied with the following equipment: (list mobility aids, respiratory equipment, etc.) We request to have Fidelco accommodate the following special needs: (to be reviewed for consideration)Equipment Details*Accommodation Details*Consent of EnrollmentSubmitting this enrollment form is the first step in reserving your child's spot in the session of your choice. Please note that a Waiver of Liability and payment will need to be received prior to securing the reservation. Both the Waiver and Credit Card Authorization Forms are provided in the 2020 Dog Days of Summer enrollment package found on the event landing page; a link to these forms will also be provided on your screen confirmation and via email once this form is submitted. For your security, please DO NOT email your credit card payment details.Payment will be provided via:Check (mail with Waiver)Credit Card (call 860-243-5200x4049/mail Waiver)Credit Card (mail CC Auth Form with Waiver)Consent* I am a parent or legal guardian of the child being enrolled in the 2020 Dog Days of Summer Program.By checking this box, I am giving consent to enroll the named child in Fidelco Guide Dog Foundation's 2020 Dog Days of Summer Program.Re-Type Parent/Guardian Name*NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.