Your Details (* = required field)

First Name*

Last Name*

Address*

Address (Line 2)

Address (Line 3)

Town*

County*

Postcode*

Home Phone Number*

Mobile Phone Number*

Relationship to Child*

E-mail Address* (you will use this to log in)

Confirm E-mail Address*

Password* (you will use this to log in)

Confirm Password*

Child Details - Child 1

First Name*

Last Name*

Known allergies / physical limitations / concerns

Date of Birth*

Gender*

Male Female

Secondary Contact

Name*

Relationship to Child*

Phone Number*

Questions

Have they ever been to a FootieBugs class?

Yes No

How did you hear about FootieBugs?

Join the FootieBugs mailing list?

Yes No