Children’s Program Registration

Child's Name*

First Last

Birthdate*

Age*

Email*

Phone*

Parent/Guardian Name*

First Last

Physical Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address

Street Address Address Line 2 City State ZIP Code

Complete only if different from physical address.

Emergency Contact Information

If parent cannot be contacted, who should be contacted in case of emergency?

Emergency Contact*

First Last

Emergency Contact Phone*

Please register for one program per child.

Mother Goose Time

12-23 Months

Toddler Time

24-35 Months

Story Hour

3, 4, & 5 Year Olds

This program is open to Tri-Valley residents only.*

Comments

This field is for validation purposes and should be left unchanged.