Rose City Veggie Kids Registration

Parent/Gardian:*

First NameLast Name
Registration Form

Kids club for ages 4-10 years of age
Phone:*

Area CodePhone Number
E-mail:*
Zip code where kids reside?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does this household receive any benefits such as:

Child's Name:*

First NameLast Name
Birth Date:*

MonthDayYear
Age:*
Grade Completed:*
- Child
- Child's Name:
  
  First NameLast Name
- Birth Date:
  
  MonthDayYear
- Age:
- Grade Completed:
- Child
- Child's Name:
  
  First NameLast Name
- Birth Date:
  
  MonthDayYear
- Age:
- Grade Completed:
- Child
- Child's Name:
  
  First NameLast Name
- Birth Date:
  
  MonthDayYear
- Age:
- Grade Completed:
- Child
- Child's Name:
  
  First NameLast Name
- Birth Date:
  
  MonthDayYear
- Age:
- Grade Completed:
- Child
- Child's Name:
  
  First NameLast Name
- Birth Date:
  
  MonthDayYear
- Age:
- Grade Completed:
- Child
- Child's Name:
  
  First NameLast Name
- Birth Date:
  
  MonthDayYear
- Age:
- Grade Completed:

I consent to let my child participate in Rose City Veggie Kids Club. Rose City Farmers Market and its staff and volunteers, and East Texas Brewing Company are hereby released from liability.
Yes
Parent's Name:

First NameLast Name
Should be Empty: