Little Lights Registration

Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Cell Phone

(###)

###

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Registering for

Please check all that apply

Fall M/W

Fall T/R

Spring M/W

Spring T/R

Summer

Parent/Guardian *

First Name

Last Name

Phone *

(###)

###

####

Work Phone *

(###)

###

####

Parent/Guardian *

First Name

Last Name

Phone *

(###)

###

####

Work Phone *

(###)

###

####

Physician's Phone *

(###)

###

####

Emergency Contact *

Emergency contact in case a parent cannot be reached.

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Authorized to pick up?

Yes

No

Who Else Is Authorized to Pick Up Your Child?

First Name

Last Name

Phone

(###)

###

####