Welcome to the Light of Pine Community!

Please complete this form to register.

Mother's name

First Name

Last Name

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Phone

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Payment Tier

Check one

Tier 1 (give financial support to another family) $200

Tier 2 (standard cost) $150

Tier 3 (receive financial support) $100

Drop in ($30)

Drop Ins Only:

Please write the date/s you plan to drop in.

Child's name

First Name

Last Name

Child's name

First Name

Last Name

Child's birthdate

Emergency Contact

Please add a name and phone number of who we can contact in the event of an emergency

(###)

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Please read and acknowledge

I understand that I am solely responsible for the safety of myself and my child.

Yes