Let's Make a Difference: Child Registration Form
Please fill out all of the following questions. If you have more than one child enrolling please fill out separate forms for each child.
Child's First and Last Name *
Child's Home Address *
Child's Age *
Child's Grade *
Child's School *
Child's Gender
Child's Race
Who does your child live with *
Father's Name (if not applicable write N/A) *
Mother's Name (if not applicable write N/A) *
Guardian's Name (if not applicable write N/A) *
Parent/Guardian's Phone Number *
Parent/Guardian's Email Address *
Preferred method of being contacted for event updates on LMAD activities and events *
Emergency Contact Person's Name *
Emergency Contact Person's Phone Number *
Does your child have food allergies? *
If your child has food allergies, what are they?
Does your child have any medical issues we should know about? *
Do you give permission to use your child's photo in LMAD printed and online publications *
Is there anything else you'd like to tell us about your child? *
Please type your full name as a virtual signature *
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