Conscious Kids Mindfulness Class Registration

Conscious Child Preschool and Learning Center

Educating the whole child: mind, body and spirit
All registrations are received and reviewed in a first come, first serve basis. Class size is limited to 16 kids. Upon filling all open spots, all additional submissions will be added to our waiting list.

**Classes are $10 class. Students must commit to a month of classes to enroll.
Conscious Kids Mindfulness Class Registration
Student Information
First Name*
Last Name*
Gender*

FemaleMale
Birth Date*

MonthDayYear
Home Phone*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information 1
Full Name*

First NameLast Name
Home*

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
E-mail*
Address - Same As Child*

YesNo
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 / Province

Postal / Zip CodeCountry
Parent/Guardian Information 2
Full Name

First NameLast Name
Home

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
E-mail
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 / Province

Postal / Zip CodeCountry
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?
Does your child require any medication? If yes, please list these medications.
Comments
Should be Empty:

Conscious Child Preschool and Learning Center

Conscious Kids Mindfulness Class Registration

Student Information

Parent/Guardian Information 1

Parent/Guardian Information 2

Other Infomation