TEST ENROLLMENT

PARENT/GUARDIAN INFORMATION

Enrolling Parent/Guardian Full Name

Relationship to Child

Phone

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Employer

Employer Address

Employer Phone

Add a Second Parent/ Guardian

CHILD INFORMATION

Child Name

Gender

Birthday

Check all that apply

Allergy

Dietary Restriction

Health/Medical Condition

Other

Tell us anything else that will help us best support your child’s needs

Add Additional Child

EMERGENCY INFORMATION

Parents cannot be listed as emergency contacts. In the event of an emergency and I am unable to be reached, I authorize the following person/s to pick up my child(ren). At least one person must be within one hour of the center/home and should be at least 18 years of age.

Emergency Contact

Relationship to Child

Phone

Additional Emergency Contact

Hospital Preference

Address

Skidaddles has permission to secure emergency transportation for my child/ren in the event of an illness or injury which requires emergency treatement. The emergency transportation serivce will determine the facility to which my child will be transported.

ACKNOWLEDGMENT OF POLICIES AND PROCEDURES

I have reviewed and received a copy of Skidaddles Policies and Procedures Handbook

Yes

HOW'D YOU HEAR ABOUT US?

Please let us know how you discovered Skidaddles.

Please tell us more. If you selected Referral, please include the name of the person who referred you and their contact info. We gift referrals! If you selected Community Event, News, Employer or Local Business, or Other, please specify the name.

What service are you enrolling in?

Enrollment Fee

$95