Wufoo

Class or Camp Child Will Be Attending
Cell Phone Number ### - ### - ####
Allergies / Special Health Considerations
Child's Name First Last
Date of Birth MM / DD / YYYY
Street Address
City, Zip Code
Home Phone ### - ### - ####
E-mail Address
Mother's Name First Last
Mom's Buisness Phone ### - ### - ####
Father's Name First Last
Father's Buisness Phone ### - ### - ####
Physician's Phone Number ### - ### - ####
Insurance Provider
Policy Number
Emergency Contact Information

I, the undersigned, authorize the staff of Creative Kids Corner to take what emergency medical measures are deemed necessary for the care and protection of my child enrolled in the Creative Kids Corner program. Please fill out the following information about two people that can be contacted in case of an emergency (when a parental figure cannot be reached).
Name of Contact 1 First Last
Relationship to Child (relative, friend, sitter)
Contact 1's Phone Number ### - ### - ####
Name of Contact 2 First Last
Relationship to Child (relative, friend, sitter)
Contact 2's Phone Number ### - ### - ####
Online Verification
By checking here I grant the same authorization as stated and valid as if signed.
Photo Permission and Release Form

I, the undersigned, authorize Creative Kids Corner (CKC) to occasionally photograph or videotape my child(ren) solely for the purpose to promote Creative Kids Corner programs.
Online Verification
By checking here I grant the same authorization as stated and valid as if signed.
What Else Would You Like Us To Know?

PLEASE use this space for additional comments: (more information concerning allergies, medications,or other information that might be helpful to us in understanding your child.
Do Not Fill This Out

Wufoo

Emergency Contact Information

Photo Permission and Release Form