I am registering: *

One Child

Two Children

Three Children

Child #1 Name *

First Name

Last Name

Child #1 Date of Birth *

MM

DD

YYYY

Parent/Guardian #1 Name *

First Name

Last Name

Parent/Guardian #1 Home Phone Number *

(###)

###

####

Parent/Guardian #1 Cell Phone Number

(###)

###

####

Parent/Guardian #1 Alternate Phone Number

(###)

###

####

Parent/Guardian #1 Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian #2 Name

First Name

Last Name

Parent/Guardian #2 Home Phone Number

(###)

###

####

Parent/Guardian #2 Cell Phone Number

(###)

###

####

Parent/Guardian #2 Alternate Phone Number

(###)

###

####

Parent/Guardian #2 Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child lives with:

Mother

Father

Both

Other

Are there custody arrangements we should be aware of?

No

Yes

Emergency Contact #1 Name

First Name

Last Name

Emergency Contact #1 Phone

(###)

###

####

Emergency Contact #2 Name

First Name

Last Name

Emergency Contact #2 Phone

(###)

###

####

Are you new to Kids Club House?

If you are a new family joining the club, we have a $25 one-time registration fee.

Yes, we're new here!

No, I'm already a part of the KCH family

Almost Done!

Social Media: We love to share your child’s fun activities throughout the day with photos on our website or Facebook page. Images are never “tagged” by us and students are not identified by name in the pictures. “Sharing” your child’s photos are a great way to keep family and friends updated on your child’s success in school! May we share your child’s experience during school with pictures on our website?

Yes

No

Social Media Permission *

May we post pictures of your child for you to enjoy on our social media? NOTE: We don’t tag/name images.

Yes

No

Class List

May we include your family on your child’s class list to share with other class members?

Yes

No

How did you hear about Kids Club House?

Family/Friends/Neighbor

Drove by school

Website

Facebook

Instagram

Birthday Party

Other

Parent Name *

A Non-refundable/Non-transferrable $25 Family Registration Fee for new families is due upon registration. I hereby understand that all charges incurring by my child attending classes will be paid on the first day of classes unless other payment arrangements are made. I am the person who will be responsible for payments and any balance on the account.

First Name

Last Name

Today's Date

MM

DD

YYYY