06.20.13

Items denoted with a red asterisk * are required.
 * Child's Name
 
 * Child's Birthdate
 
 * Home Address
 
Address 1
Address 2
City
State
Zip Code
 * Home Phone Number
 
 -  - 
(XXX)-XXX-XXXX
 * Mother's Name
 
 * Mother's cell phone
 
 -  - 
(XXX)-XXX-XXXX
Father's Name
 
 * Father's cell phone
 
 -  - 
(XXX)-XXX-XXXX
 * How will your child go home?
 
 * Who has permission to pick up your child?
 
 * Do I have permission to put your child's picture on the internet?