• Child's Information

  • Name * Required
  • Address * Required
  • Mother's / Legal Guardian's Information

  • Name
  • Home Address
  • Business Address
  • Father's / Legal Guardian's Information

  • Name
  • Home Address
  • Business Address
  • Emergency Contact Person(s)

  • #1 Name
  • #2 Name
  • #3 Name
  • Person(s) to Whom Child May be Released

  • #1 Name
  • #1 Address
  • #2 Name
  • #2 Address
  • #3 Name
  • #3 Address
  • Child's Physician / Medical Care Provider

  • Address
  • Parent's Signature is Required for Each Item Below to Indicate Parental Consent

  • This field is for validation purposes and should be left unchanged.