Ckids Registration

Ckids REGISTRATION
CHILD INFORMATION
Child's Name*

First Name Last Name
Child's Birthday*

Month Day Year
Child's Age*
School*
Grade*
Please list any allergies that your child may have.
PARENT INFORMATION
Parent's Name (1)*

First Name Last Name
Parent's Home Phone (1)*

Area Code Phone Number
Parent's Cell Phone (1)*

Area Code Phone Number
Parent's Email Address (1)*
Parent's Name (2)

First Name Last Name
Parent's Cell Phone (2)

Area Code Phone Number
Comments/Questions:
The cost to enroll in this program is $100. Please choose one of the following payment options:
Payment Options*

Full payment now of $100 Pay by Check
Click to verify Full Payment of $100

$100

Payment

Credit Card

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Check if you would like to sponsor another child for this club.
Signature*
For any questions or concerns please contact Chaya Rochel at chayarochel@yahoo.com or (516)-592-2384.
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