Child programs Registration Form

Child Registration
What programs are you registering for?

Nursery (infant to age 5) Kids on the Move (K - 5th grade) Little Lambs (ages 3-6) Lighthouse Kids (ages 7-10)
Child Information
Child's Name *

First Name Last Name
Child Nickname
Birth Date

Month Day Year
Grade
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Parent/Guardian Information
Parent/ Guardian Name

First Name Last Name
Home Number

Area Code Phone Number
Cell Number

Area Code Phone Number
E-mail
Parent/ Guardian Name

First Name Last Name
Home Number

Area Code Phone Number
Cell Number

Area Code Phone Number
E-mail
example@example.com
Best Number to reach you

Area Code Phone Number
Preferred method of contact

Phone Call Text Email
Additional Information
Other Person authorized to pick up child

First Name Last Name
Phone Number

Area Code Phone Number
Other Person authorized to pick up child

First Name Last Name
Phone Number

Area Code Phone Number
Please list any allergies including food and reactions.
Does your child need/ have an epic pen?
Is there anything else you would like us to know about your child?
If your child has anxiety, attention/behavior issues, are there accommodations and behavior strategies you use to help your child focus and/or calm down?
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Person Completing form

First Name Last Name
Signature
Date form completed

Month Day Year
Date
Should be Empty:

Child Registration