Registration Form v2 | Kids Clubhouse

CHILD REGISTRATION

Other than parent/guardian, who has permission to pick up your child? All authorized persons will be required to show drivers license/ID to verify their identity. If possible, please have all authorized pick up persons supply a thumbprint for our ID system.

In case of emergency, we need the name of at least one non-parent authorized to pick up your child. KCML will call both parents first before calling emergency contacts.

If there is somebody who DOES NOT have permission to pick up your child, please list here.

Health Information. You must also submit the physician form located here.

Does your child have any allergies, including drugs?

Yes

Does your child use regular medications?

Yes

Parent Signature

Does your child have specific medical concerns?

Yes

Date

Your electronic signature above signifies that everything on this form is true and that you are the legal parent/guardian of this child.

Go to Physician Form and Payment