Bridge Kidz Registration

Student Information

Student First Name

Last Name

Birthdate

Age

Grade

Food Allergy/ Intolerance

Please choose one of the following:

My Child is Potty trained - you will be contacted to take them

My Child is in diapers - a worker may change their diaper if necessary

My Child is in diapers - please contact me to change their diaper

Guardian 1: First Name

Last Name

Phone Number

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Guardian 2: First Name

Last Name

Phone Number

Any other authorized pick up person(s)

Signature

Date Input