Evolve KidsCare Free State Convention Registration

Evolve KidsCare Registration

Onsite childcare for families attending the Free State Regional Convention of NA
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.

PARENT/GUARDIAN MUST REMAIN ONSITE!
- Age Range: Childcare services are available for children aged 3 to 10 years and MUST be fully potty trained.
- Cost: A suggested donation of $10 per child is requested.
- Health and Safety: All caregivers are trained in first aid and CPR. We adhere to strict hygiene and safety protocols.
- Special Needs: Please inform us of any special requirements your child may have in the registration form, and we will make the necessary accommodations.
All additional information can be found at: https://evolvekidscare.org/evolve-kidscare-at-the-free-state-regional-convention-of-na/
Which event are you registering for?*
The event is from 12PM-10PM. Do you plan to attend for a half day session or a full day session?*
How did you hear about Evolve KidsCare?*
CHILD INFORMATION
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Home Phone
Parent/Guardian Information 1
Full Name*

First NameLast Name
Home
Cell*
Work
Parent E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Parent/Guardian 1 Address

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Information 2
Full Name

First NameLast Name
Home
Cell
Work
E-mail
example@example.com
Address - Same As Childs

YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Other Infomation
Does your child have any allergies?*

YesNo
If yes please list, including any food or drug allergies.
Does your child have any medical conditions?*

YesNo
If yes, please list below.
Please list below any behavioral information or special accommodations your child may need, if applicable.
Please list the people authorized to pick up your child.*
Comments
Emergency Contact 1 - Other than Parent/Guardian
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home
Cell*
Work
Emergency Contact 2 - Other than Parent/Guardian
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home
prevnext( X )
Child Registration Donation
$10.00 Quantity

Total

$0.00
Signature*

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Payment Methods

Debit or Credit Card

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Evolve KidsCare Registration

CHILD INFORMATION

Parent/Guardian Information 1

Parent/Guardian Information 2

Other Infomation

Emergency Contact 1 - Other than Parent/Guardian

Emergency Contact 2 - Other than Parent/Guardian