Child's Name *

Child's Name

First Name

Last Name

Child's Birthdate *

Child's Birthdate

MM

DD

YYYY

Sibling 1

Sibling 1

First Name

Last Name

Birthdate

Birthdate

MM

DD

YYYY

Sibling 2

Sibling 2

First Name

Last Name

Birthdate

Birthdate

MM

DD

YYYY

Parent/Guardian 1 *

Parent/Guardian 1

First Name

Last Name

Phone *

Phone

(###)

###

####

Alt. Phone

Alt. Phone

Optional

(###)

###

####

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 2

Parent/Guardian 2

Optional

First Name

Last Name

Phone

Phone

(###)

###

####

Caretaker or other adult accompanying child to class

Caretaker or other adult accompanying child to class

Required information if child will not be accompanied by a parent or guardian.

First Name

Last Name

Phone

Phone

(###)

###

####