Baby Power Bronx Online Registration

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Open Gym / Play DateBirthday Party
Date Requested
Time Requested
Participant Information
Child's Birth Date

MonthDayYear
Child Name
Parent/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Cell Phone
E-mail
Siblings Enrolled

YesNo
Names
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I hereby certify that my child has no food allergies.My child has the following food or other allergies or dietary restrictions:
Please describe
Fees

A Representative will contact you with the cost of your tuition fees. We accept credit card payments by phone for your convenience.
I hereby release Baby Power, from all claims resulting from injury, not directly caused by the negligent actions of Baby Power, while participating in a Baby Power/Forever Kids program.
Guardian Name
Date

MonthDayYear
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