Play and Learn Group Registration Form

Parent/Legal Guardian 1 Information
Help for First and Last Name First and Last Name
Help for Street Address Be sure to add the house, building, or apartment number.
Parent/Legal Guardian 2 Information
Help for Street Address Be sure to include the house, building, or apartment number.
CHILD 1 Information (under 5 years of age)
MM/DD/YYYY
Child 1 Race (check all that apply) Help for Child 1 Race (check all that apply) Demographic data is based upon collected by grant funders
Child 1 Gender at Birth
CHILD 2 Information (under 5 years of age)
MM/DD/YYYY
Child 2 Race (select all that apply)
Child 2 Gender Assigned at Birth
CHILD 3 Information (under 5 years of age)
MM/DD/YYYY
Child 3 Race (check all that apply)
Child 3 Gender Assigned at Birth
Family Information
Choose the school district where you reside.
Where did you hear about our program?
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Register now for the playgroup you wish to attend. 

Choose only one group per family. Register on the Wait List if your group of choice is currently full.