The Kids' Clubhouse Online Registration

Registration

Already a customer? Click here to login.

Welcome to The Kids' Clubhouse! We are thrilled you're here! We've made enrolling your children easy and convenient. Please complete the following registration form. If you are looking to enroll for classes or full day care, please see the following directions: *Once you have completed registration, you must then log into your portal. *Select "Classes & Events". *Select "Find Classes". *From here, you can register for any days you need!

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)*

Health Insurance Carrier*

Alternate Pick Up:*

Alternate Pick Up:

Contact #1

Contact #1 First Name*

Last Name *

Relationship*

How Can We Contact You?

Home Phone

Work # *

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Who is your employer?

Employer*

Employer Phone*

Employer Notes

Contact #2

Contact #2 First Name

Last Name

Relationship*

How can we contact you?

Home Phone

Work # *

Cell # *

Email* (Emails are kept confidential)

Confirm Email*

Who is your employer?

Employer*

Employer Phone*

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School*

Grade Level*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School*

Grade Level*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School*

Grade Level*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School*

Grade Level*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School*

Grade Level*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

eCheck/Bank Draft

Required Policies

(Show-Hide Details)