Infant Registration Form

Parent/Guardian Information

Your Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Phone 2

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child Information

Name

First Name

Last Name

Age

Birthday

12/12/2017

Allergies

Please list any food and/or medication allergies, please enter N/A if this does not apply to your child.

Medications

Please list any medications your child is required to take (i.e. insulin)

Emergency

Emergency Contact Name

First Name

Last Name

Relationship

Emergency Contact Email

Emergency Contact Phone

(###)

###

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