REGISTRATION FOR PREPARED CHILDREN

Programs and Classes

Parent/Legal Guardian First Name:

Parent/Legal Guardian Last Name:

Address:

Address 2:

City:

State:

Zip Code:

Home Phone:
xxx-xxx-xxxx

Work Phone:
xxx-xxx-xxxx

Cell Phone:
xxx-xxx-xxxx

Additional Contact Name
in Case of Emergency:

Additional Contact Phone
in Case of Emergency:
xxx-xxx-xxxx

Email Address:

Child First Name:

Child Last Name:

Child Nickname:

Relationship of Registrant to Child:

Gender:

Male

Female

Birthdate:

Year   Month  Day

Age:

Rising Grade in School:

Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade

Pediatrician's Name:

Pediatrician's Phone Number:

Does child have allergies?:

Yes

No

If "yes" please list all allergies:

Is child taking medications?:

Yes

No

If "yes" please list all medications:


I understand that by checking this box I have read and accept the enrollment terms and conditions.
(For a printable PDF of Terms & Conditions Click HERE)

If you need more information email us or call 704-215-4950.