Jamie's Bananas Playgroup Registration
Please fill out this form to register for Playgroups at BANANAS. Thank you!
Email *
Phone Number/Número de teléfono *
Caregiver Name / Nombre del cuidador *
Street Address / Dirección *
City / Cuidad *
Zip Code / Codigo Postal *
Race of the Caregiver / *
Gender of Caregiver / Género del cuidador *
I'm the child's..../Soy el .....del nino
Clear selection
Name of Child #1 *
Child #1 Date Of Birth / Fecha de nacimiento de nino *
MM
/
DD
/
YYYY
Gender for Child #1 *
Child #1: Race/Ethnicity *
Name of Child #2
Child #2 Date Of Birth / Fecha de nacimiento de nino
MM
/
DD
/
YYYY
Gender for Child #2
Clear selection
Child #2: Race/Ethnicity
Clear selection
How did you hear about BANANAS Playgroups
For More Information ...
Please Contact Jamie Molina at Jamie@bananasbunch.org or text at ‪(510) 736-5321‬
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