Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Parent/Guardian 1 - Name *

First Name

Last Name

Parent/Guardian 1 - Phone Number *

(###)

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Parent/Guardian 2 - Name

First Name

Last Name

Parent/Guardian 2 - Phone Number

(###)

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Which email address should we use for class correspondence? *

We can send email correspondence to one or both parent/guardians. Please indicate your preference below.

Please send to Parent/Guardian A

Please send to Parent/Guardian B

Please send to both Parent/Guardian A and B

Nanny's Name (if applicable)

Please include your nanny or family member's name if they will be bringing your child to class on a regular basis

First Name

Last Name

Nanny's phone number (if applicable)

(###)

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Emergency Contact's Name *

First Name

Last Name

Emergency Contact's Phone Number *

(###)

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Your Pediatrician's Name *

First Name

Last Name

Your Pediatrician's Phone Number *

(###)

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I confirm that my child is up-to-date with their immunizations *

I will email a copy of my child's immunization records before the first class

I will bring a copy of my child's immunization to the park meet-up for my child's class (which is scheduled for before our first class)