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contact@brimiq.com
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Sharing Time with Sharene: Registration
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Parent Name
*
First
Last
Parent or Guardian: We collect names and birthdates so we can celebrate your child and personalize their experience. Basic family information helps us maintain a safe and trusted environment for all participants. Your information is kept private and
Email
*
Phone (include Country Code and Area Code)
Home Address, Street, City, State or Province, Zip
Name – Child 1
*
First
Last
Birth Date (month, day, year)
Name – Child 2
First
Last
Birth Date (month, day, year)
Name – Child 3
First
Last
Birth Date (month, day, year)
Name – Child 4
First
Last
on Email (month,
Birth Date (month, day, year)
Name – Child 5
First
Last
Birth Date (month, day, year)
Do you give permission for your child to be recongnized in class on his or her birthday?
Yes
No
Comments and Questions
If you would like to share special circumstances about your children, or if you have questions for our staff, please include them here and we will contact you as quickly as possible. You may also add additional children here.
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This is to confirm that you are not a robot.
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