Admission Form

Child’s Name

Name:*
Date of Birth:*
Sex:*
Allergies:*
Child’s School:*
Home Address:*
Home Telephone:*
E-mail:*
Father’s Name:*
Cell Phone:*
Work:*
Mother's Name:*
Cell Phone.:*
Work Tel.:*

Emergency Contacts: In case of emergency, who can we contact if parents cannot be reached?

Name.:*
Home Telephone.:
Physician’s Name:*
Telephone:
How did you find out about Kidbridge Kids Center?( Check all that apply):*

Kidbridge periodically sends out quarterly newsletters / current events to our enlisted parents. Your Email information is never sold or shared with other parties. This helps us to save on printing expenses.

Would you like to receive our quarterly newsletter / current events through Email? :*

A non refundable Registration fee is required to complete this registration. Your child’s space may be forfeited if child does not start Kidbridge as specified by parent.

Child’s Start Date:*
Drop off time:*
 : 
 : 
Pick up Time:*
 : 
 : 
Parent’s Name:*
Date:*
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