Child Age Group *

Infant 0 - 18 months

Toddler 18 months - 2.5 years

Preschooler 2.5 – 4 years

Child's Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Gender

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Phone (Optional)

(###)

###

####

Mother's Name *

First Name

Last Name

Home Phone

(###)

###

####

Cell Phone *

(###)

###

####

Business Phone

(###)

###

####

Father's Name *

First Name

Last Name

Home Phone

(###)

###

####

Cell Phone *

(###)

###

####

Business Phone

(###)

###

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Confirmation of Intent *

By submitting this Waiting List I/We confirm my/our intention to register the child named above at kidzLIFE when the Centre commences operation in 2022