Client Information Form

Butterfly Youth Registration

Please fill in the form below
Client's Name*

First NameMiddle NameLast Name
Date of Birth*
School
Grade Level
Race
Gender*
Preferred Language
Do you have additional children you would like in the program?

YesNo
Full Name Date of Birth Female Male
Parent or Guardian Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Does Parent or Guardian have Legal Custody?*
In case of emergency...
Emergency Contact:

First NameLast Name
Relationship
Contact Number

Area CodePhone Number