Registration Form

Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Parent | Guardian*

First NameLast Name
Relationship to Student?*
Best Contact Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you allow your child to be photographed or video taped for promotional purposes of this program?*

YesNo
Parent or Guardian Signature*
By signing this form, I consent to receive additional information from 1200 Kids Korner regarding enrollment opportunities and related updates.
Should be Empty: