Registration Form

registration and emergency form

step 1 of 6: passenger information

* = Required field

* First name:
* Last name:

Male Female
* Date of birth (mm/dd/yy):
/ /

Street address at which child resides most frequently (number and name):

Apartment or unit number:

City:
State:
Zip code:

* Phone number at the address entered above
( ) - Type

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

* Primary Contact's main phone number
( ) - Type

Would you like to add another phone number?
E-mail address of Primary Contact: