Parent/Guardian Name *

First Name

Last Name

Total Number Adults (or Youth over age 12) Attending Breakfast *

1

2

3

4

Total Number Children Ages Infant to age 3 attending *

none

1

2

3

Total Number Children Ages 4 to 7 attending *

none

1

2

3

Total Number Children Ages 8 to 12 attending

none

1

2

3