Child’s Name* Name the Child Goes By* Child’s Date of birth* Child Age* Child’s Address
Parent/Guardians Name* Occupation Address (If different from Child) Phone Number*
Yes No Email
Monday Tuesday Wednesday Thurday
Once a week Twice a week More… If other, please specify
I (Your Name here) certify that the information provided on this form, is correct and give permission for Playful Learners to use this information for my child’s educational experience pertaining to, but not exclusive to: child registration and curriculum creation.
