Soaring Kidz Program Registration: Art for All - Winter 2017
Soaring Kidz Registration Form
Child's Name *
Date Of Birth (mm/dd/yyyy) *
Age *
Registration Sport or Event *
Shirt Size *
Mother’s Name
Father’s Name
E-mail *
Primary Phone *
Secondary Phone
Address *
City *
State *
Zip Code *
Child Diagnosis *
Child’s Doctor *
Emergency Contact *
Emergency Phone *
Please read and respond to the following to help us serve your child better *
(Check All That Apply)
Required
Please provide any helpful strategies for our staff to assist your child in adjusting:
How does your child communicate? *
Required
Are there any other special considerations you would like us to know?
Has there been any changes in your child’s medical condition or status since the previous program?
MANDATORY PHYSICIAN RELEASE MUST BE COMPLETED AND RECEIVED BY SOARING KIDZ TO PARTICIPATE
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