Parents Name *

First Name

Last Name

Childs Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent's Phone *

Country

(###)

###

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Childs Birthday *

MM

DD

YYYY

Emergency Contact Name (other than parent) *

First Name

Last Name

Emergency Contact Phone (other than parent) *

(###)

###

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Do we have permission to use your childs image and likeness *

Yes

No