PLAYTIME DAY 1st PREFERENCE *

Check the day you prefer attending (one day only please)

TUESDAYS

WEDNESDAYS

THURSDAYS

ANY DAY

PLAYTIME DAY 2nd PREFERENCE *

Check another day if the 1st preference day is not available

TUESDAYS

WEDNESDAYS

THURSDAYS

ANY DAY

I CANNOT ATTEND ON ANY OTHER DAY

Date Today *

MM

DD

YYYY

Parent/Carer First and Last Name *

First Name

Last Name

Parent/Carer Birthdate *

MM

DD

YYYY

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of an Emergency Contact Person : (not yourself) *

First Name

Last Name

Child's Name *

First Name

Last Name

Childs Birthdate *

MM

DD

YYYY

Sex of Child *

Male

Female

2nd Child's Name

First Name

Last Name

2nd Child's Birthdate

MM

DD

YYYY

Sex of Child

Male

Female

Do you know anyone who attends Playtime? *

Yes

No