SMILE Child Registration Form

Please fill out a separate form for each child you register.

Parent's Name

Child's Full Name

Phone Number

Email Address

Full Address

Child's Birthday

Age as of September 30, 2016

Does your child have any allergies or other restrictions?

Are there any bathroom/diapering issues we should know about?

Any general information to know your child better?

If under age 1, any special instructions for naps and feeding?

12 + 13 =