New Customer Registration Form

WillowTree Children's Society

Additional Pickup Persons Form
Child's Details:
Child's Full Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Persons other than legal guardians or already listed contacts who are allowed to pick up your child.
Please let staff know in advance if anyone other than legal guardians will be picking up your child.
Contact 1 *

First NameLast Name
Contact 1 Phone (Main)*
Please enter a valid phone number.Format: (000) 000-0000.
Contact 1 Phone (Other)
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child*
Notes:
If this person is only allowed to pick up in certain situations (Ex. for Preschool Only) add that here.

Contact 2

First NameLast Name
Contact 2 Phone (Main)
Please enter a valid phone number.Format: (000) 000-0000.
Contact 2 Phone (Other)
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child
Notes:
If this person is only allowed to pick up in certain situations (Ex. for Preschool Only) add that here.
Contact 3

First NameLast Name
Contact 3 Phone (Main)
Please enter a valid phone number.Format: (000) 000-0000.
Contact 3 Phone (Other)
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child
Notes:
If this person is only allowed to pick up in certain situations (Ex. for Preschool Only) add that here.
Contact 4

First NameLast Name
Contact 4 Phone (Main)
Please enter a valid phone number.Format: (000) 000-0000.
Contact 4 Phone (Other)
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child
Notes:
If this person is only allowed to pick up in certain situations (Ex. for Preschool Only) add that here.
Parent Signature*

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WillowTree Children's Society