IKIDZ : 2018-2019 AFTERSCHOOL REGISTRATION FORM

IKIDZ LEARNING CENTER (Mowry-Fremont)

www.ikidzlearning.com

After School Registration Form 2020-2021
Student Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Grade entering in Fall 2020*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact E-mail-1*
Contact E-mail - 2*
example@example.com
Phone Number - 1*

Area CodePhone Number
Phone Number - 2*

Area CodePhone Number
School Attending*
Do you require pick up from school?*
IKIDZ After-School Start Date*

MonthDayYear
Date
Parent's Name*

First NameLast Name
Emergency Contact Information (other than parents listed in the form) Include Name, Phone number*
List names of people who are authorized to pick up your child from the center.*
Physician's Contact Information in case of emergency*
Any allergies or medical conditions that we need to know about *
We acknowledge that we have received and read your policies and will comply with it.*

YesNo
Please initial below by typing your first name*
Should be Empty: