LCC Kids Contact Info Form
Please fill out this form and click submit.
Parent/Guardian 1
Name
*
Gender
*
Please select one option.
Male
Female
Email
*
This address will receive a confirmation email
Phone
*
Address
*
--
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Relationship to Child
*
Please select one option.
Parent
Grandparent
Relative
Friend
Other
Select Option
Parent
Grandparent
Relative
Friend
Other
Parent/Guardian 2
Name
Gender
Please select one option.
Male
Female
Email
Phone
Address (if different from above)
--
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Relationship to Child
Please select one option.
Parent
Grandparent
Relative
Friend
Other
Select Option
Parent
Grandparent
Relative
Friend
Other
Child(ren) Info
Child 1
Name
*
Gender
*
Please select one option.
Male
Female
Birthdate (ex. MM/DD/YYYY)
*
Address (where child resides, if different from above address)
--
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Grade
*
Please select one option.
Nursery (6mo - 1y)
2 year olds
3 year olds
Pre K
Kindergarten
First
Second
Third
Fourth
Fifth
Select Option
Nursery (6mo - 1y)
2 year olds
3 year olds
Pre K
Kindergarten
First
Second
Third
Fourth
Fifth
List any Allergies
Child 2
Name
Gender
Please select one option.
Male
Female
Birthdate (ex. MM/DD/YYYY)
Address (where child resides, if different from above address)
Grade
Please select one option.
Nursery (6mo - 1y)
2 year olds
3 year olds
Pre-K
Kindergarten
First
Second
Third
Fourth
Fifth
Select Option
Nursery (6mo - 1y)
2 year olds
3 year olds
Pre-K
Kindergarten
First
Second
Third
Fourth
Fifth
List any Allergies
Child 3
Name
Gender
Please select one option.
Male
Female
Birthdate (ex. MM/DD/YYYY)
Address (where child resides, if different from above address)
Grade
Please select one option.
Nursery (6mo - 1y)
2 year olds
3 year olds
Pre-K
Kindergarten
First
Second
Third
Fourth
Fifth
Select Option
Nursery (6mo - 1y)
2 year olds
3 year olds
Pre-K
Kindergarten
First
Second
Third
Fourth
Fifth
List any Allergies
Child 4
Name
Gender
Please select one option.
Male
Female
Birthdate (ex. MM/DD/YYYY)
Address (where child resides, if different from above address)
Grade
Please select one option.
Nursery (6mo - 1y)
2 year olds
3 year olds
Pre-K
Kindergarten
First
Second
Third
Fourth
Fifth
Select Option
Nursery (6mo - 1y)
2 year olds
3 year olds
Pre-K
Kindergarten
First
Second
Third
Fourth
Fifth
List any Allergies
Child 5
Name
Gender
Please select one option.
Male
Female
Birthdate (ex. MM/DD/YYYY)
Address (where child resides, if different from above address)
Grade
Please select one option.
Nursery (6mo - 1y)
2 year olds
3 year olds
Pre-K
Kindergarten
First
Second
Third
Fourth
Fifth
Select Option
Nursery (6mo - 1y)
2 year olds
3 year olds
Pre-K
Kindergarten
First
Second
Third
Fourth
Fifth
List any Allergies
Submit
Description
Please fill out this form and click submit.
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