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registration and emergency form
step 1 of 6: passenger information
* = Required field
* First name:
* Last name:
Male
Female
* Date of birth (mm/dd/yy):
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Street address at which child resides most frequently (number and name):
Apartment or unit number:
City:
State:
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Zip code:
* Phone number at the address entered above
(
)
-
Type
Cell
Home
Work-Direct
Work-Main
Any medical conditions or special needs of which the driver should be aware
(medications, allergies, etc.):
To help ensure each rider’s safety and well-being, Go Kid Go asks for a Primary Contact, a person who knows the rider, the details of his or her rides, and who has the authority to take action on his or her behalf. The Primary Contact will be the first person Go Kid Go attempts to contact, should it become necessary.
* First Name of Primary Contact:
* Last Name of Primary Contact:
* What is the Primary Contact's relationship to the rider?
select
Mother
Father
Grandmother
Grandfather
Guardian
Aunt
Uncle
Sister
Brother
Principal
Teacher
Counselor
Social Worker
Other
* Primary Contact's main phone number
(
)
-
Type
Cell
Home
Work-Direct
Work-Main
* Alternate phone number
(
)
-
Type
Cell
Home
Work-Direct
Work-Main
* Alternate phone number
(
)
-
Type
Cell
Home
Work-Direct
Work-Main
Would you like to add another phone number?
E-mail address of Primary Contact:
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