Kids Club 2023 Registration Form

Kids Club Registration Form

Fill out the form carefully for registration. Only children aged 12 & under are eligible for Kids Club.
Child 1 Name

First NameLast Name
Child 1 Birth Date

MonthDayYear
Child 2 Name

First NameLast Name
Child 2 Birth Date

MonthDayYear
Child 3 Name

First NameLast Name
Child 3 Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Phone Number
Parent's Riverbend Co-op Number*
Yes, you may contact me by email regarding Co-op Kids Club Membership & Activities.
If you elect to opt-in, your email address will be used to contact you regarding Kids Club membership activities.

The Co-op respects your privacy and will adminster personal information that you provide to it by way of this Kids Clubs application in accordance with its privacy policies and related practices. The personal information that you provide to the Co-op is being collected and may be used for one or more of the following purposes:
- Address may be used to send birthday cards and other communications related to Kids Club activities.
- Phone number may be used for general contact purposes related to this application or related Kids Club activities
- Birthdate will be used to confirm eligibility for Kids Club and may be used to send birthday cards.
I consent for the use of my child's personal information to join Co-op's Kids Club and for my child to participate in Co-op Kids Club activities.
Signature*

Clear
Parent's Name*

First NameLast Name
Date Signed

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Kids Club Registration Form