Riverside Kids Registration

Child's Information

Please note all information is kept confidential and is used soley for the purpose of caring for your child in our programs, and / or for emergency use.

Child First Name *

Child Last Name *

Date of Birth *

Gender *

School Grade (if attending grade school)

Care Card # *

Home Phone Number *

Tip: Use Cell phone if no home phone number

Home Address

Home City

Home Province

Home Postal Code

Allergies *

Tip: If none, please specify 'None'

Does your child have support needs? If so, please describe below so we can partner with you for your child's benefit.

Special needs/disability *

Tip: If none, please specify 'None'

Choose Event *

Nursery 0-24 months (Riverside Community Church, 2329 Fremont Connector, Port Coquitlam, V3B 0M3)
Dec 31, 2023 10:00 AM
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Preschool 4 & 5 years (Riverside Community Church, 2329 Fremont Connector, Port Coquitlam, V3B 0M3)
Dec 31, 2023 10:00 AM
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Preschool 2 & 3 years (Riverside Community Church, 2329 Fremont Connector, Port Coquitlam, V3B 0M3)
Dec 31, 2023 10:00 AM
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Elementary Gr. 1-4 (Riverside Community Church, 2329 Fremont Connector, Port Coquitlam, V3B 0M3)
Dec 31, 2023 10:00 AM
Cancel Accept Decline

Parents' Information/Emergency Contact

Contact Home/Cell Phone *

Tip: Please enter the phone number you will be reachable at, and indicate whether it is cell or home

Contact Full Name *

Contact email *

Contact relationship *