Individual Registration

Please enter information in the form below to process registration for event Play & Learn Classes - for ages 2 to 4 yrs (Fri 10:30 to 11:15am).

Child First Name *

Child Last Name *

Address *

Address 2

City *

State *

Zip *

Birthdate *

Gender *

male

female

Does your child have any allergies or health issues we need to be aware of? *

Parent #1 Information

Name (Parent #1) *

Address (Parent #1) *

City (Parent #1) *

State (Parent #1) *

Zip (Parent #1) *

Phone (Parent #1) *

Email (Parent #1) *

Parent #2 Information

Name (Parent #2)

Address (Parent #2)

City (Parent #2)

Zip (Parent #2)

State (Parent #2)

Phone (Parent #2)

Email (Parent #2)

Emergency Contact Information (other than parents listed above)

Name (Emergency Contact) *

Address (Emergency Contact) *

City (Emergency Contact) *

State (Emergency Contact) *

Zip (Emergency Contact) *

Phone (Emergency Contact) *

Email (Emergency Contact)

Emergency contact relationship to child *

parent

grandparent

relative

friend

babysitter / nanny

Waiver Information

You have my permission to email me class-related information and announcements. I understand that my personal information is for the exclusive use of communication from Welcome Little Ones Learning Center LLC. You have my permission to use photographs or video of myself or my child taken at classes or special events that could also be used on the Welcome Little Ones Facebook page or blog. With this enrollment, I release any and all rights and claims for damages against Welcome Little Ones Learning Center LLC and its Staff in the unlikely event of injury sustained by myself or my child(ren) during the course of or as a result of my enrollment.

Have you read and agreed to the waiver? *

yes

Payment Information

Coupon

Amount

Discount Amount

Gross amount

Payment Method

Paypal

Billing Zipcode*

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Type*

Card Holder Name*

Verification code*