Evolve KidsCare Free State Convention 2025 Registration

Evolve KidsCare Registration 2025

Onsite childcare for families attending the Free State Regional Convention of NA on Saturday, November 29, 2025
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!
- Date: Saturday 11/29/2025 - 12PM-10PM (multiple sessions available)
- 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, but none will be turned away from lack of payment
- Health and Safety: A caregiver trained in first aid and CPR will be in attendance the whole time. 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.
By signing this form, you areeing to the following terms and conditions:
- Must drop-off your child no earlier than 12PM and pick-up no later than 10PM
- Must have phone available to receive contact from staff and respond within 5 minutes
- Must pick up your child for the remainder of the day if contacted by staff for any incident - including but not limited to: bathroom incident, behavior incident, injury, illness.
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? Choose the time range if you plan to pick children up early.*
How did you hear about Evolve KidsCare?*
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

If applicable
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
CHILD INFORMATION
Child 1 Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Child 2 Name (If applicable)

First NameLast Name
Date of Birth

MonthDayYear
Date
Child 3 Name (If applicable)

First NameLast Name
Date of Birth

MonthDayYear
Date
Child 4 Name (If applicable)

First NameLast Name
Date of Birth

MonthDayYear
Date
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 none, please put N/A *
Please list the people authorized to pick up your child - include full name, relationship to child, and phone number.*
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 (optional)
$10.00 Quantity

Total

$0.00
Signature*

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Payment Methods

Debit or Credit Card

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Evolve KidsCare Registration 2025

Parent/Guardian Information 1

Parent/Guardian Information 2

CHILD INFORMATION

Other Infomation

Emergency Contact 1 - Other than Parent/Guardian

Emergency Contact 2 - Other than Parent/Guardian