Connect the Tots Registration | UCP of Greater Dane County

Child's Name *

First

Last

Date of Birth *

Race (optional):

Ethnicity (optional):

Primary Language:

Language:

Parent/Legal Guardian Name *

First

Last

Additional Parent/Legal Guardian Name

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

By checking the box, I give UCP staff permission to contact me in the following ways:

I would like to register for Connect the Tots sessions in the following community: *

This Session's theme is "Ocean Explorers." We are registering for the following dates: *

This Session's theme is "Ocean Explorers." We are registering for the following dates: *

This Session's theme is "Ocean Explorers" We are registering for the following dates: *

Total

$0.00

Bill Registration to: *

Case Manager Name *

Case Manager Email *

Case Manager Phone

Bill to Other (Please Explain):