NXT Gen Kidz Registration Form

NXT Kidz

Registration Form
Child*

First NameLast Name
Birthday*

MonthDayYear
Date
Grade*
Parent/Guardian*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Emergency Contact other than Parent/Guardian*

First NameLast Name
Emergency Phone Number other than Parent/Guardian*

Area CodePhone Number
Does your child have any medical issues or allergies that we need to be aware of? Please explain.*
May we have permission to share your child's photo on our social media*

YESNO
If you would like to stay up to date with our children's programs, subscribe to our NEWSLETTER!
example@example.com
Should be Empty:

NXT Kidz