Child's Name: *
Child's Name:
Child's Gender: *
Child's Date of Birth: *
Child's Date of Birth:
Name of Parent #1: *
Name of Parent #1:
Name of Parent #2:
Name of Parent #2:
Street Address: *
Street Address:
Home Telephone:
Home Telephone:
Parent/Caregiver's Cell Phone: *
Parent/Caregiver's Cell Phone:
May we have permission to photograph your child? *
May we have permission to use your child's photograph for the purpose of promotion? *
Emergency Phone Contact Number: *
Emergency Phone Contact Number: