Membership Enrollment

To register and submit payment for the $35 Membership Fee, please complete the form below.

Please provide an Emergency Contact other than Mom or Dad

Parent's or Guardian's Information

Name:

Address:

City:

State:

Zip:

Phone:

Email:

Child Information Child #1

Name:	Male Female	Birthday:
Allergies or Special Needs:

Child #2

Name:	Male Female	Birthday:
Allergies or Special Needs:

Child #3

Name:	Male Female	Birthday:
Allergies or Special Needs:

Child #4

Name:	Male Female	Birthday:
Allergies or Special Needs:

Contact and Release

Give the name, address, and phone number of the person to call in case of an emergency if parents/guardian can not be reached:


Name	Address

Phone	Relationship

Give the names and telephone numbers of persons to whom your child may be released:

Name	Phone

In the event that I can not be reached, to make arrangements for emergency medical attention at the time of illness or accidents, I authorize Wanna Play PlayCare to take my child to :


Name of Physician	Address

Phone Number

Name of Clinic/Hospital	Address

Phone Number

I give consent for Wanna Play PlayCare to secure any and all necessary emergency medical care for my child.

By submitting this form, I agree to all of Wanna Play PlayCare policies

After clicking submit, you will be forwarded to a payment screen. A receipt will be forwarded to your email address.

Current Immunization Records must be presented upon your child's first visit or a statement documenting your child has records on file at a preschool or elementary school must be signed.

Membership Enrollment

To register and submit payment for the $35 Membership Fee, please complete the form below.

Thank you

We're looking forward to meeting you and your family!