Empowered Minds Kids Studio on Fox Cities Fridays

Parent Information

Parent Name

Address

Email

Phone

Child’s Information

Child’s Name

Birthdate

Name of School

Medical Information

Pediatrician’s Name

Pediatrician’s Number

Allergies

Special Accomodations

Emergency Contact

Name

Number

Relationship to child

Billing Address

Your Address

Street Address Address Line 2 City State ZIP Code

Payment Information

Coupon

Price(Required)

Price: $0.00

Total

Credit Card(Required)

Card Details

Cardholder Name

Name

This field is for validation purposes and should be left unchanged.

SEND US A MESSAGE!