Child's Name *

First Name

Last Name

Child's Birth Date *

MM

DD

YYYY

Grade in School *

Pre-K

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Cell *

(###)

###

####

Work Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

May we have permission to photograph your child? *

Yes, you may photograph my child.

No, you may not photograph my child

May we have permission to use your child's photograph for the purpose of promotion? *

Yes, you may use my child's photograph for promotion.

No, you may not use my child's photograph for promotion.