Village Kids Registration Form
Child's (1) Name
First Name
Last Name
Child's (2) Name
First Name
Last Name
Child's (3) Name
First Name
Last Name
Child's (4) Name
First Name
Last Name
Child (1) Date of Birth
-
Month
-
Day
Year
Date
Child (2) Date of Birth
-
Month
-
Day
Year
Date
Child (3) Date of Birth
-
Month
-
Day
Year
Date
Child (4) Date of Birth
-
Month
-
Day
Year
Date
Parent/Guardian
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Getting to know your child(ren).
Is your child (1) allowed to have snacks?
Yes
No
Is your child (1) allergic to anything?
Yes
No
Please list your child's name and any food allergy or medical conditions that we need to be aware of.
Is your child (2) allowed to have snacks?
Yes
No
Is your child (2) allergic to anything?
Yes
No
Please list your child's name and any food allergy or medical conditions that we need to be aware of.
Is your child (3) allowed to have snacks?
Yes
No
Is your child (3) allergic to anything?
Yes
No
Please list your child's name and any food allergy of medical conditions that we need to be aware of.
Is your child (4) allowed to have snacks?
Yes
No
Is your child (4) allergic to anything?
Yes
No
Please list your child's name and any food allergy or medical conditions what we need to be aware of.
In Case of Emergency
Please note the names of two people who only may pick up your child from Village Kids.
First Trustee Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Second Trustee Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Signature
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Submit
Submit
Next
Signature Date
-
Month
-
Day
Year
Date
Should be Empty: