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Child Registration
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* Indicates required question
Child's Name
*
Your answer
Child's Gender
*
Male
Female
Child's Birth Date
*
MM
/
DD
/
YYYY
Last Grade Completed?
*
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Other:
Any Allergies? (Select all that apply)
*
Peanut
Tree nut (Use Other to Specify)
Food Dye (Use Other to Specify)
Lactose Intolerant
Gluten
None
Other:
Required
Other Medical Information
*
Your answer
Days attending?
Monday
Tuesday
Wednesday
Thursday
Friday
Street Address
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
Phone number
*
Your answer
Parent's Name
*
Your answer
Parent's Gender
*
Male
Female
Parent's Email
Your answer
Is there an emergency contact other than the parent?
*
Yes
No
Emergency Contact: Name
Your answer
Emergency Contact: Phone
Your answer
What is 2 + 2?
*
Your answer
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