CCC Kids Registration Form

Please fill out this form and click submit.

Parent/Guardian 1

First Name

Last Name

Gender

Please select one option.

Male Female

Email

Phone

Address

Relationship to Child

Please select one option.

Parent Grandparent Relative Friend Other

Parent/Guardian 2

First Name

Last Name

Gender

Please select one option.

Male Female

Email

Phone

Address (if different from above)

Relationship to Child

Please select one option.

Parent Grandparent Relative Friend Other

Child(ren) Info

Child 1

Name

Gender

Please select one option.

Male Female

Birthdate (ex. MM/DD/YYYY

Address (where child resides, if different from above address)

Classroom

Please select one option.

Nursery (1-3) 4-10 Class

List any Allergies

Child 2

Name

Gender

Please select one option.

Male Female

Birthdate (ex. MM/DD/YYYY

Address (where child resides, if different from above address)

Classroom

Please select one option.

Nursery (1-3) 4-10 Class

List any Allergies

Child 3

Name

Gender

Please select one option.

Male Female

Birthdate (ex. MM/DD/YYYY

Address (where child resides, if different from above address)

Classroom

Please select one option.

Nursery (1-3) 4-10 Class

List any Allergies

Child 4

Name

Gender

Please select one option.

Male Female

Birthdate (ex. MM/DD/YYYY

Address (where child resides, if different from above address)

Classroom

Please select one option.

Nursery (1-3) 4-10 Class

List any Allergies

Child 5

Name

Gender

Please select one option.

Male Female

Birthdate (MM/DD/YYYY)

Address (where child resides, if different from above address)

Classroom

Please select one option.

Nursery (1-3) 4-10 Class

List any Allergies

Description

Please fill out this form and click submit.

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