First Coast Taekwondo - Kickin' Kids Registration

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 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
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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