Registration

Parents Information
Mother's Name
First Last
Mother's Phone
Mother's Email
Mother's Occupation
Father's Name
First Last
Father's Phone
Father's Email
Father's Occupation
Emergency Contact (other than parent)
First Last
Cell Phone
Home Phone
Relation to the child
Child's Information
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Birth date
Child's School
Grade as of 2019-20 school year
Please list any allergies and/or medical conditions that we should be aware of*
Health Insurance Name
Health Insurance Number
- In case of medical emergency requiring immediate emergency care, I authorize the paramedics to take my child to the nearest hospital, if necessary.
What are your child's favorite activities?*
What makes your child upset?*
Does your child occasionally exhibit any of the following behaviors?
- Biting
- Cursing
- Grabbing
- Hitting
- Kicking
- Pulling Hair
What is the best method of handling the situation?

Parents Information