Parent Registration Form for Precious Moments Learning Center

1
Student's Name
First Name
Last Name
2
Student's Phone Number
Please enter a valid phone number.
3
Student Birthday
Date
Month
Day
Year
4
Student Age
Please Select
Please Select
6
7
8
9
10
11
12
13
5
I, the undersigned parent or legal guardian of the above-named child, give permission for my child to participate in cooking classes and related activities.
6
* This field is required.
7
* This field is required.
8
Does your child have any food allergies or intolerances?
Yes
No
9
Please select your child's food allergies below.
10
3. Allergies & Medical Conditions: I have disclosed all known allergies, dietary restrictions, and medical conditions below: If you ticked any of the above boxes please provide further details of the nature of the allergy/intolerance and dietary restrictions:
11
Does your child carry an EpiPen or autoinjector?
Yes
No
12
Terms and Conditions
13
Terms and Conditions
14
* This field is required.
15
Do you give permission for your child to be included in photos or videos?
I constent
I do not constent
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* This field is required.
17
* This field is required.
18
Emergency Contact
First Name
Last Name
19
Emergency Contact Phone Number
20
Name of Parent/Guardian
First Name
Last Name
21
Phone Number Parent/Guardian
Please enter a valid phone number.
22
Date
Date
Month
Day
Year
23
Signature
24
The Young Chef Experience by Pics Flicks & Confetti
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The Young Chef Experience by Pics Flicks & Confetti

Looking for a fun, hands-on activity for your child this summer?

Join us for a 2-Day Kids Cooking Class designed for ages 6–13!

· Led by a professionally trained chef
· Small group setting (only 15 spots!)

Please note: Precious Moments Learning Center Staff will setup all payment arrangements. **

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