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Registration Form: PIMC Youth Dharma Program
Initial Child Registration Form (1st Visit)
NOTE: For multiple children, please use one form per child.
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* Indicates required question
Child's Legal Name:
*
Your answer
Child's Preferred Name:
Your answer
Child's Age:
*
Your answer
Child's DOB:
*
MM
/
DD
/
YYYY
Child's Pronouns:
*
Your answer
Parent/Caregiver Name(s):
*
Your answer
Home Address:
*
Your answer
Phone(s):
*
Your answer
Email(s):
*
Your answer
What are your child's strengths or special interests?
*
Your answer
Does your child have food allergies? If so, please list.
*
Your answer
Does your child have any special needs?
*
Your answer
Name(s) of anyone else authorized to accompany your child to the center:
Your answer
Emergency contact name and phone number:
*
Your answer
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