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Contact Information

Phone: 512-402-0077
Address: 1508 RR 620 South, Lakeway, TX 78734

Mon-Thurs 9am-10pm

Fri & Sat 9am-Midnight

Sunday Noon-8pm



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Children Enrollment Form
Child Enrollment Form
 
 Parent/Guardian Information (Parent/Guardian information is required. The 4 fields with asterisks must be filled)
 Last Name:* First Name:*
 Home Phone:* Work Phone:
 Address:
 Email:
 City: State:
 Zip: Relationship to Child:*
 
 Child Information  (Information is required for at least 1 child. For every child entered, the first 6 fields must be filled)
 Child 1
 Last Name:* First Name:*
 Birth Date:* Sex:*
 Starting Date:* Program Name:*

 Allergies or Special

 Needs:
 Child 2
 Last Name: First Name:
 Birth Date: Sex:
 Starting Date: Program Name:

 Allergies or Special

 Needs:
 Child 3      
 Last Name: First Name:
 Birth Date: Sex:
 Starting Date: Program Name:
 Allergies or Special

 Needs:
 Child 4      
 Last Name: First Name:
 Birth Date: Sex:
 Starting Date: Program Name:
 Allergies or Special

 Needs:
 
 Medical Information
 Doctor's Information (Doctor's information is not required. However, if entering the Doctor's information, all 3 text fields must be filled)
 Doctor's Last Name: Doctor's First Name:
 Phone #:    
 Insurance Information
 Insurance Provider : Policy #:
 
 Additional Contacts (Additional contacts are not required. However, if entering a contact, the first 4 fields for that contact must be filled)
 Emergency Contact 1
 Last Name: First Name:
 Relationship: Phone #:
 Can Pickup Child?    
 Emergency Contact 2
 Last Name: First Name: 
 Relationship: Phone #:
 Can Pickup Child?    
 Emergency Contact 3
 Last Name: First Name:
 Relationship: Phone #:
 Can Pickup Child?    
 
(By submitting this form, I agree to all of Kid-E-Shack's policies)

Printable Child Registration Form
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