Moms & Tots

Parent Name: *

First Name Last Name

Were you registered for our Winter 2018 Moms & Tots session?

Yes (if no changes, please skip to Submit button) No (please fill out entire registration form)

Parent E-Mail Address: *

example@example.com

Parent Phone #: *

- Area Code Phone Number

Parent Address: *

Street Address
Street Address Line 2
City	Province
Postal Code	Country

Child #1 Name: *

First Name Last Name

Child #1 Birth Date: *

Date

Child #1 Food Allergies? *

Yes No

If YES, please describe below:

If you only have one child attending, please disregard Child #2 section and proceed to the next section.

Child #2 Name:

First Name Last Name

Child #2 Birth Date:

Date

Child #2 Food Allergies?

Yes No

If YES, please describe below:

Emergency Contact Name: *

First Name Last Name

Emergency Contact Phone #: *

- Area Code Phone Number

Photo Disclaimer (please check box to acknowledge): *

I am aware that pictures and videos of my child(ren) may be taken at The Salvation Army Brantford Community Church Moms and Tots program which may be used in promotional material. Pictures and Videos used are considered property of The Salvation Army Brantford Community Church and will not be sold or reused without the express consent of the current Pastor at The Salvation Army Brantford Community Church.

Registration Form