Registration Form for Kids' Connection
(Please complete, and we'll contact you regarding availability.)

Parents' home phone number (with country, city, area codes):

Father's work phone:  Company:

Mother's work phone:  Company:

Home Address:
City/Town:	State/Prov.: Post./Zip Code:
Country:

Child's Name
Nickname (If any)
Child's Gender (Choose One) Male  Female

Child's Date of Birth

Does your child have any special needs? Please be specific.

Other options which might help me, include:
Parent-Teacher Conferences
Parenting Workshops
Drop-in Services
Family Vacation Time
Second Child Discounts
Financial Assistance

Do you have any Questions for us?

Thank you for your interest. We will process your inquiry as soon as possible. Please note: Although it is most unlikely that you will experience any problems responding to this form, certain non-standard browsers will not respond properly. If you experience any difficulties, (or if you are not using a forms-capable browser) you may email your response to this form to: wabash@iquest.net.