Child Intake Form

All first-time members are required to have a completed form on file before booking or after confirmation. Thank you.

Email *
Child#1 Name, Gender, and Age
Child#2 Name, Gender, and Age
Primary Contact
This person will be contacted in case of emergency or in general if needed.
Name and Relation
Address
Primary Phone Number
Child's Medical History
Indicate any serious conditions, allergies, or illnesses (If Any)
Health Goals or Dietary Restrictions
List any developmental concerns (If Any)
Environment
Is the child in school?
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What are your child's favorite activities?
How much television does your child watch per week?
Are there animals in the home? (If so, please specify)
Submit
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