Child's First Name *

Child's Last Name *

Phone *

Email *

Emergency Contact - Name and Phone *

My child will most likely eat: *

Cereal will be purchased from Aldi and will have no artificial colors. Milk offered will be 2%.

Does your child have any allergies that staff should be aware of?

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Participation Waiver

I agree to the participation waiver. *

Yes

Marketing Release

I agree to the marketing release *

Yes

Signature *

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