Burnt Hickory FastPass

We are so glad you have decided to visit BHBC Kids.  In order to make your first visit more enjoyable and to save you time when dropping off your child, please complete this FAST PASS information.  IMPORTANT:  Please include a parent/guardian cell phone # for emergency contact and click the SUBMIT button at the bottom of the form when done.  You will receive a confirmation email. Thank you and we look forward to your first visit with us.

*Parent or Legal Guardian First Name:
*Parent or Legal Guardian Last Name:
*Parent or Legal Guardian Marital Status:
*Parent or Legal Guardian Email Address:
*Parent or Legal Guardian Cell Phone Number xxxxxxxxxx:
2nd Parent or Legal Guardian First Name:
2nd Parent or Legal Guardian Last Name:
2nd Parent or Legal Guardian Marital Status:
2nd Parent or Legal Guardian Email Address:
2nd Parent or Legal Guardian Cell Phone Number xxxxxxxxxx:
*Address Line 1:
Address Line 2:
*City:
*State:
*Zip Code:
Home Phone xxxxxxxxxx:
I am open to receiving follow-up and giving feedback regarding my visit to BHBC:

Child 1

*Child's First Name
*Child's Last Name
*Child 1 Gender:
*Child's Birthdate
*Does Child 1 have any allergies or special needs:
If answered yes above, list child's Allergies/special Needs:

Child 2

Child's First Name
Child's Last Name
Child 2 Gender:
Child's Birthdate
Does Child 2 have any allergies or special needs:
If answered yes above, list child 2 Allergies/special Needs:

Child 3

Child's First Name
Child's Last Name
Child 3 Gender:
Child's Birthdate
Does Child 3 have any allergies or special needs:
If answered yes above, list child 3 Allergies/special Needs:

Child 4

Child's First Name
Child's Last Name
Child 4 Gender:
Child's Birthdate
Does Child 4 have any allergies or special needs:
If answered yes above, list child 4 Allergies/special Needs:

Child 5

Child's First Name
Child's Last Name
Child 5 Gender:
Child's Birthdate
Does Child 5 have any allergies or special needs:
If answered yes above, list child 5 Allergies/special Needs: