Kids Only Registration Child's Name * First Name Last Name Child's Date of Birth MM DD YYYY Parent/Guardian Name First Name Last Name Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Allergies Emergency Contact Authorization As parent and/or guardian, I do authorize the treatment of the following minor(s) by qualified and licensed medical doctor(s), in the event of a medical emergency, which, in the opinion of the attending physician, may endanger the child’s life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me. Please Sign Below. Select Number of Days/Classes 1 Day/Class - $93 for 10 installments 2 Days/Classes - $167 for 10 installments 3 Days/Classes - $237 for 10 installments Choice of Days Please check the days you would like to sign up for Monday (9:20-11:20) Monday (11:45-1:45) Wednesday (9:20-11:20) Wednesday (11:45-1:45) Friday (9:20-11:20) Sign Your Name: Date MM DD YYYY Thank you for choosing Kids Club House!
