XtremeKids Information Card
Parent Name
*
First Name
Last Name
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Spouse Name
*
First Name
Last Name
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Children
Please list children individually.
Number of Children
*
1
2
3
4
5
Child Name
*
First Name
Last Name
*
Male
Female
Grade/Class
*
Nursery 6 weeks to 24 months
2 & 3 Yr Old
Preschool and Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
Birthday
*
-
Month
-
Day
Year
Date
Please list any Health/Behavioral Concerns
Child Name
*
First Name
Last Name
*
Male
Female
Grade/Class
*
Nursery 6 weeks to 24 months
2 & 3 Yr Old
Preschool and Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
Birthday
*
-
Month
-
Day
Year
Date
Please list any Health/Behavioral Concerns
Child Name
*
First Name
Last Name
*
Male
Female
Grade/Class
*
Nursery 6 weeks to 24 months
2 & 3 Yr Old
Preschool and Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
Birthday
*
-
Month
-
Day
Year
Date
Please list any Health/Behavioral Concerns
Child Name
*
First Name
Last Name
*
Male
Female
Grade/Class
*
Nursery 6 weeks to 24 months
2 & 3 Yr Old
Preschool and Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
Birthday
*
-
Month
-
Day
Year
Date
Please list any Health/Behavioral Concerns
Child Name
*
First Name
Last Name
*
Male
Female
Grade/Class
*
Nursery 6 weeks to 24 months
2 & 3 Yr Old
Preschool and Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
Birthday
*
-
Month
-
Day
Year
Date
Please list any Health/Behavioral Concerns
Submit
Should be Empty: