Cultivate! Children's Program Registration Form
Date: *
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DD
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YYYY
Participant's Name: *
Your answer
Age: *
Your answer
Address: *
Your answer
Grade: *
Home Phone: *
Your answer
Cell Phone (if applicable):
Your answer
Parent's (Or Responsible Party) Name: *
Your answer
Address: *
Cell Phone: *
Your answer
Okay to Text? *
Relationship to Child: *
Your answer
Who referred you to this program? *
Your answer
In Case of Emergency Contact: *
Your answer
Phone Number(s): *
Your answer
Relationship to Participant: *
Your answer
Others that may pick up the participant from this program: *
Your answer
By signing this registration form, both the participant and the parent/responsible party of the participant acknowledge that due to limited space available, if the participant misses more than two (2) classes, his/her spot may be given to another participant. By typing my full name below, I give my permission for the above named child to participate in the kids program and I commit to providing transportation and support during this program. I give my permission for this child to be photographed in group photos for marketing purposes only. *
Your answer
I, the participant of the Cultivate! Club, commit to be an active participant in the club, by typing my name below. *
Your answer
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