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This ‘Family Health Form’, allows you to share or update important family information (ex. emergency & authorized pick up contacts or health notes) with our staff before your experience at Mini U.  To ensure your child’s safety we ask that you submit/resubmit detailed information with each registration.  Please indicate any information related to health, medication or special needs that our staff should be aware of.

Authorized Pick Up/Parent/Guardian Contacts:

 
Parent/Guardian 1 Name:
 
 
Parent/Guardian 1 Home Phone:
 
Please enter in this exact format 000-000-0000
 
Parent/Guardian 1 Business/Daytime Phone:
 
Please enter in this exact format 000-000-0000
 
 
Parent/Guardian 1 Cell Phone:
 
Please enter in this exact format 000-000-0000
 
 
Parent/Guardian 2 Name:
 
 
 
Parent/Guardian 2 Home Phone:
 
Please enter in this exact format 000-000-0000
 
 
Parent/Guardian 2 Business/Daytime Phone:
 
Please enter in this exact format 000-000-0000
 
 
Parent/Guardian 2 Cell Phone:
 
Please enter in this exact format 000-000-0000
 
Alternate Contact Name other than Parent/Guardian:
 
 
Alternate Contact Home Phone:
 
Please enter in this exact format 000-000-0000
 
 
Alternate Contact Business/Daytime Phone:
 
Please enter in this exact format 000-000-0000
 
 
Alternate Contact Cell Phone:
 
Please enter in this exact format 000-000-0000
 
 

Add a child to your family:

  • Child's Last Name
  • Child's First Name
  • Birthdate mm/dd/yyyy
  • Gender
 
 
Family Mailing Address & Email

Family Mailing Address

 
 
Family Mailing Address City
 
 
Family Mailing Address Postal Code
 
 
Email Address