Fall Kidz Club Registration Form
Full name of child
First Name
Middle Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Gender
Boy
Girl
Full name of child
First Name
Middle Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Gender
Boy
Girl
Full name of child
First Name
Middle Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Gender
Boy
Girl
Parent/Guardian's Name
First Name
Middle 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
Additional Parent/Guardian's 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
Person to call in case of emergency
First Name
Last Name
Person(s) authorized to pick up child
First Name
Middle Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Person(s) authorized to pick up child
First Name
Middle Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Name
First Name
Middle Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
There is a $50 Non-Fundable Registration Fee and the cost is $300 per month, please choose yes or no to understanding and consenting to the cost.
*
Please Select
Yes
No
Signature of child care provider
Signature of parent
Submit
Should be Empty: