Playground Playdate Registration Form

Playground Playdate Registration

We're excited to have you join us for a Playdate! Please complete the following information so that we can best accommodate your preferences.
Yes, I would like to purchase a Playdate Package of 10 visits. *YOU WILL BE REDIRECTED TO ANOTHER PAGE TO PURCHASE YOUR PACKAGE*No, I would like to continue without purchasing a 10-visit pass.I already have Playdate passes available.
Parent / Guardian Name*

First NameLast Name
Email Address
example@example.com
Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Parent / Guardian Name*

First NameLast Name
Email Address
example@example.com
Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
1 child2 children3 children4 children
Name of child*

First NameLast Name
Child Date of Birth*

MonthDayYear
Child's Age (Please include "years" or "months"
Name of child*

First NameLast Name
Child Date of Birth*

MonthDayYear
Child's Age (Please include "years" or "months"
Name of child*

First NameLast Name
Child Date of Birth*

MonthDayYear
Child's Age (Please include "years" or "months"
Name of child*

First NameLast Name
Child Date of Birth*

MonthDayYear
Child's Age (Please include "years" or "months"
Please add names and ages of infants under 9 months here, and share any special needs or requests, or any other information that would make your visit better. We'll try our best to accommodate.
Session Selection: Indicate the number of children who will be playing for each session time. (Please contact us if you would like to make an availability request)*

My Products

Playground Playdate

Each child (over 9 months of age) needs a paid registration to attend. *You may purchase 4 reservations to ensure a private session for your group/family. *If you have more than 4 children, please contact us, and we will try to accommodate you. *Playdate Package codes should be entered in the coupon box below, after you've made your selection here.*

$35.00 Number of children attending
Item subtotal:$0.00

Purchased Package of 10 visits

We will deduct from your remaining purchased visits.

$ Free Quantity
Item subtotal:$0.00

Playdates Included in Therapy Package

Some therapy packages include 4 Playdate visits per quarter. Eligible packages are: Caterpillar, Butterfly, Fly Away

$ Free Quantity

Enter coupon

Total

$0.00

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty: