Registration Main Form

Parent/Guardian 2 Information:
If Parent/Guardian 2 Information is unavailable, please click Next on the bottom of the page.
Other Parent/Guardian Name:
Relationship to Child:*
Address:
Street Address Address Line 2 City State ZIP Code
Home Phone:
Work Phone:
Work Address:
Street Address Address Line 2 City State ZIP Code
Cell Phone:
Email
Where can you be reached while your child is at Skidaddles?*

Emergency Contact Information 1:
Contact must be local to the center.
In the event of an emergency and I am unable to be reached, I authorize the following persons to pick up my children:
Name:*
Home Phone:*
Cell Phone:*
Address*
City State / Province / Region
Relationship:*
-
- Add another contact?
Emergency Contact Information 2:
Contact must be local to the center.
Name:
Home Phone:
Cell Phone:
Address
City State / Province / Region
Relationship:

Name of Physician:*
Phone:*
Hospital Preference:*
Consent for Medical Treatment:
I give consent for Skidaddles to secure any and all necessary medical care for my child.
Enrolling Parent/Guardian Name 1:*
Please enter full name.
Signature*
Today's Date:*
Date Format: MM slash DD slash YYYY
Enrolling Parent/Guardian Name 2:
Please enter full name.
Signature
Today's Date:
Date Format: MM slash DD slash YYYY

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