Lloydminster and District Co-op
Kids Club
Kids Club Registration
Child's Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian's Name
*
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Co-op Number
Add me to the monthly Kids Club email list!
*
Yes
No
By clicking the submit button, you agree to our terms & conditions.
*
Parent/Guardian's Signature
*
To register another child, kindly fill out a new application.
Submit
Clear Form
Should be Empty: