Registration Form

Today’s date:
MM slash DD slash YYYY
Child’s Name:*
Surname First
Child’s Age:
Parent full Names:
First Last
Parent full Names:
First Last
Parent’s Signature:

Any Adult name authorised to pick up your child:
Parent Emergency Phone Number 1:
Parent Emergency Phone Number 2:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Does your child have any allergies we should be aware of?*
- Yes
- No
What are the allergies? And what type of reaction?
Any foods to be given in moderation?
Anything we need to be aware of regarding your child: