Your Details

First Name*

Last Name*

Address*

Relationship to Child*

Address (Line 2)

E-mail Address* (you will use this to log in)

Address (Line 3)

Confirm E-mail Address*

Town*

County*

Password* (you will use this to log in)

Postcode*

Confirm Password*

Home Phone Number*

Mobile Phone Number*

Child Details - Child 1

First Name*

Last Name*

Known allergies / physical limitations / concerns

Date of Birth*

Gender*

Male Female

Secondary Contact

Name*

Relationship to Child*

Phone Number*

Child Details - Child 2 (optional)

First Name

Last Name

Known allergies / physical limitations / concerns

Date of Birth

Gender

Male Female

Secondary Contact

Name

Relationship to Child

Phone Number

Questions

Have they ever been to a FootieBugs class?

Yes No

How did you hear about FootieBugs?

Join the FootieBugs mailing list?

Yes No