kidXplosion

ONLINE REGISTRATION


Please use the form below to enter your children's information. If you are only registering one child, you can ignore the second and third child options. If you need to register more than three children, please fill out a second form.

You will be contacted via email or letter to confirm your registration. Thank you.
How did you hear about us?


Name of First Child: First:
Last:

Birthday: //
Age After June 22: Grade Completed:    
Known Allergies and/or Special Needs:
Office Use Only
Family ID: Group Name:

Name of Second Child: First:
Last:

Birthday: //
Age After June 22: Grade Completed:    
Known Allergies and/or Special Needs:
Office Use Only
Family ID: Group Name:

Name of Third Child: First:
Last:

Birthday: //
Age After June 22: Grade Completed:    
Known Allergies and/or Special Needs:
Office Use Only
Family ID: Group Name:

Parent Name: Parent's Evening Phone:

Email Address:

Home Address: Apt #:
City:    State:    ZIP:

In case you can't be reached...
Emergency Contact's Name:
Emergency Contact's Phone:

In the event of an emergency, do we have your permission to get your child to a hospital?
Yes:    No:
Please list all people (including yourself) who are allowed to pick-up your children:

All  required fields  are marked with a yellow background.