First Coast Taekwondo - Kickin' Kids Registration
Kickin' Kids After School Program
STUDENT'S INFORMATION
Child's Full Legal Name
*
Preferred Name
Child's Gender
*
Male
Female
Child's Date of Birth
*
MM
/
DD
/
YYYY
Elementary School Name
Please select
Argyle
Chimney Lakes
ELA
Gregory Drive
Jax Heights
Oakleaf Village
Plantation Oaks
Sadie Tillis
Westview
Other
Please select your child's school for the 2013-2014 school year. If the his/her school is not listed, select other and put their school name in the comment field.
Child's Grade 2013-2014 School Year
Please select
kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
START DATE IN OUR AFTER SCHOOL PROGRAM
(Clay County starts Tuesday, 8/13/13 and Duval County starts Monday, 8/19/13)
MM
/
DD
/
YYYY
Days Attending After School Program
Monday
Tuesday
Wednesday
Thursday
Friday
Has child had any of the following: (if yes, please explain below in the Special Needs of Child field)
*
Surgery
Serious Illness/Accident
Allergies
None of the Above
Any Special Needs of Child?
PARENT INFORMATION
Note: If one of the fields does not apply, put N/A. Thank you.
Mother's Name
Prefix
First
Last
Suffix
Mother's Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Mother's Cell Phone Number
###
-
###
-
####
Mother's Home Phone Number
###
-
###
-
####
Mother's Work Phone Number
###
-
###
-
####
Mother's Email Address
*
Mother's Employer
Father's Name
Prefix
First
Last
Suffix
Father's Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Father's Home Phone Number
###
-
###
-
####
Father's Cell Phone Number
###
-
###
-
####
Father's Work Phone Number
###
-
###
-
####
Father's Email Address
Father's Employer
AUTHORIZED PICK-UP (other than parent/guardian)
Authorized Pick-Up (other than parent/guardian)
The child will be released only to the parent(s) authorized, or in the manner authorized in writing, by the custodial parent(s) or legal guardians(s). The following people are authorized to remove the child from the facility in case of illness, accident or emergency, if for some reason the custodial parent(s) or legal guardian(s) cannot be reached:
1. First and Last Name of individual authorized to pick-up
Phone Number
###
-
###
-
####
2. First and Last Name of individual authorized to pick-up
Phone Number
###
-
###
-
####
I agree to all the above conditions and terms of service.
*
I agree
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