ChapelKids Registration

Parent's Information

Parent's Name

Relationship to child?

If other, please specify here:

Mailing Address

Email Address

Phone Number

Preferred Method of Contact

Email Me

Call Me

Child(s) Information:

Child #1 Name/Age/Date of birth/School

Child #2 Name/Age/Date of birth/School

Child #3 Name/Age/Date of birth/School

If child #1 is under 3 years of age:

Is he/she walking?

Yes

No

Is he/she potty trained?

Yes

No

If Child #2 is under 3 years of age:

Is he/she walking?

Yes

No

Is he/she potty trained?

Yes

No

If Child #3 is under 3 years of age:

Is he/she walking?

Yes

No

Is he/she potty trained?

Yes

No

Thank you for taking the time to complete this form. Please provide any comments or concerns you may have in the box below. Please include any allergies or special needs your child may have. *Please provide information for additional children here.

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