DREAM BIG FOR YOUR KIDS Register by September 14, 2018 by filling out this form: Parent / Caregiver Name(s) Street Address City State Zip Code Phone Number Email Please check: - Select -WE AGREE TO ATTEND ALL SIX WORKSHOPS AS A PARTICIPATING FAMILY IN THE BORN LEARNING ACADEMY Child 1 Name Child 1 Birthday Child 1 Age Child 2 Name Child 2 Birthday Child 2 Age Child 3 Name Child 3 Birthday Child 3 Age Child 4 Name Child 4 Birthday Child 4 Age Attending Dinner? - Select -Yes No If yes, number of adults: If yes, number of children: Food Allergies: - None -Yes No If yes, please list: Dietary Restrictions: - None -Yes No If yes, please list: Do you need childcare for your child(ren) during the workshops? - Select -Yes No If yes, number of non-school age children and their ages: If yes, number of school age children and their ages: Please Pick one: - None -I would like to receive email reminders for workshops. I would like to receive text message reminders for workshops. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit Leave this field blank
