Leadership Impact Childcare Registration

Childcare Registration for birth-5th grade

Parent Name:

Division of Leadership (ie...Children, Youth, Adult)

Phone:

Email:

Child1 Name:

Child1 DOB:

Child1 Age:

Child1 Grade (if applicable):

Child1 Known Allergies:

Child2 Name:

Child2 DOB:

Child2 Age:

Child2 Grade (if applicable):

Child2 Known Allergies:

Child3 Name:

Child3 DOB:

Child3 Age:

Child3 Grade (if applicable):

Child3 Known Allergies:

Child4 Name:

Child4 DOB:

Child4 Age:

Child4 Grade (if applicable):

Child4 Known Allergies: