Admission Form

Child’s Name

Home Address:*
Date of Birth:*
Child’s School:
Father's Information
Father’s Name:*
Cell Phone:*

Mother's Information

Mother's Name:*
Work Tel.:*
Cell Phone: *

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

Name: *
Physician’s Name:*
Home Telephone.:*
Telephone: *

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.

How did you find out about Kidbridge Kids Center?( Check all that apply):
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 the child does not start Kidbridge as specified by the parent.

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