Jax PBS Kids Club
Please fill out ALL the following information to enroll your child(ren) into the Jax PBS Kids Club.
Parent First Name *
Parent Last Name *
Mailing Address *
City *
State *
Zip Code *
Primary Phone *
Primary Email *
Relationship to Child(ren) *
Child #1 First Name *
Child #1 Last Name *
Child's #1 Gender *
Child's #1 Date of Birth (include year) *
Child #2 First Name
Child #2 Last Name
Child #2 Gender
Clear selection
Child #2 Date of Birth (include year)
Child #3 First Name
Child #3 Last Name
Child #3 Gender
Clear selection
Child #3 Date of Birth (include year)
Child #4 First Name
Child #4 Last Name
Child #4 Gender
Clear selection
Child #4 Date of Birth (include year)
Child #5 First Name
Child #5 Last Name
Child #5 Gender
Clear selection
Child #5 Date of Birth (include year)
MM
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DD
/
YYYY
Child #6 First Name
Child #6 Last Name
Child #6 Gender
Clear selection
Child #6 Date of Birth (include year)
MM
/
DD
/
YYYY
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