Kidsregistration

Shelby Alliance Kids Registration Form

Parent 1 Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Parent 2 Name *

First

Last

Same As Address Above? *

Yes No

Email *

Phone Number *

Alternate Pickup Name *

First

Last

Alternate Phone Number *

Emergency Contact Name *

First

Last

Emergency Phone Number *

Children Information

Child 1 Name *

First

Last

D.O.B *

Grade *

Allergies/Medical Information *

Child 2 Name *

First

Last

D.O.B *

Grade *

Allergies/Medical Information *

Child 3 Name *

First

Last

D.O.B *

Grade *

Allergies/Medical Information *

Child 4 Name *

First

Last

D.O.B *

Grade *

Allergies/Medical Information *

Child 5 Name *

First

Last

D.O.B *

Grade *

Allergies/Medical Information *

Submit