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Guardian's Name(s)*

Guardian's Phone Number*

Guardian's Email Address*

Child 1 Name

Child 1 Date of Birth

Child 2 Name

Child 2 Date of Birth

Child 3 Name

Child 3 Date of Birth

Child 4 Name

Child 4 Date of Birth

If applicable - For children ages 6 and over (who you may drop-off/pick-up), please clarify whether your child is able to use the bathroom without help (if your child can not use the bathroom with out assistance, you will be called to the Kids Room to help them as needed. No child will be assisted in the bathroom). Reminder, a parent or guardian must remain with all children under 6 at all times.

Yes No

If applicable - For ages 6 and over, do you give your youth permission to sign themselves out and leave the kids rooms without a guardian?

Yes No

Name(s) of people allowed to pick up child (please also detail their relationship to your child)*

Thank You!