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Child Registration Form
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* Indicates required question
Child Name
*
Your answer
Nickname
Your answer
Address
*
Your answer
Birthdate
MM
/
DD
/
YYYY
Parent/Guardian Info
Name
Your answer
Address (If different)
Your answer
Cell Phone
Your answer
Would you like to receive text message updates and announcements?
Yes
No
Clear selection
Work Phone
Your answer
Email
Your answer
Best way to contact you during the day.
Cell Phone
Work Phone
Text
Email
Clear selection
Name
Your answer
Address (If different)
Your answer
Email
Your answer
Cell Phone
Your answer
Would you like to receive text message updates and announcements?
Yes
No
Clear selection
Work Phone
Your answer
Best way to reach you during the day.
Cell Phone
Work Phone
Text
Email
Clear selection
Emergency Contact Information
Name
Your answer
Phone
Your answer
Email
Your answer
Relationship
Your answer
Medical Information
Food Allergies
Your answer
Any medications needed to be administered at school
Your answer
Any additional comments about your child's health that I should be made aware of.
Your answer
Media Release
I will allow my child's picture to be used for advertising, social media, and for other classroom display purposes.
Yes
No
Clear selection
What goals do you have for your child while attending this program?
Your answer
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