Co-op Kids Club Membership Form
For Children Aged 12 and Under.
Parent or Guardian Name
*
First Name
Last Name
Parent/Guardian Moose Jaw Co-op Number:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Where is your closest Co-op location?
Please Select
Moose Jaw
Avonlea
Liberty
Kid 1 Name
*
Kid 1 Birthday
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Kid 2 Name
Kid 2 Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Kid 3 Name
Kid 3 Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Kid 4 Name
Kid 4 Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Kid 5 Name
Kid 5 Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: