Kidz Into Action Registration 2023

Play4Autism

Kidz into Action Registration Form
Child One Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Child Two Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Child Three Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
AREA OF PARTICIPATION*

NYCNew JerseyBoth
Parent/Guardian name*

First NameLast Name
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
PLEASE NOTE THAT YOUR MEMBERSHIP
WILL BE FOR 2 YEARS FROM THE FIRST DAY YOU ATTEND A PROGRAM.
Number of Children*
prevnext( X )
One Child
$95.00



Two Children
$150.00



Three Children
$225.00



Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Play4Autism