Family Enrollment Form

To enroll your child in the next session of the Healthy Kids Program, please complete and submit the registration form below. You will receive a confirmation by email. If you have any questions about the program, please call 928-336-7958.

"*" indicates required fields

Child's Name*
Date of Birth*
Address*
Known Allergies:
Column 1
Column 2
Column 3
 
Parent/Guardian Name*