Child Registration Form

Child Registration Form

Registration form required for each family.
Parent's Name*

First NameLast Name
Parent's Name

First NameLast Name
Email*
example@example.com
Phone Number*
Child's Name*

First NameLast Name
Child's Name

First NameLast Name
Birth Date*

MonthDayYear
Birth Date

MonthDayYear
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of School or Facility
Pickup Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Drop off Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requested Start Date

MonthDayYear
Date
Services Needed*
Grade
Special accommodations?

Safety restraints neededBooster seat neededOne- on-one neededMultiple childrenOther
School Start Time

Hour Minutes

AM/PM Option
School End Time

Hour Minutes

AM/PM Option

Registration Fee

$35.00 Quantity

Total

$0.00