Child's Name *

First Name

Last Name

Child's date of birth *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Phone *

(###)

###

####

Parent/Guardian Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I give consent for my child's photograph to be taken for marketing (print & social media), annual report publication and reporting purposes. (Photos will be securely filed and used for official WRC purposes only.)

Yes, I give consent for my child's photo to be taken.

No, I do not give consent for my child's photo to be taken.

Nationality *

Bermudian

Spouse of a Bermudian

Non-Bermudian

Marital Status *

Check all that apply

Married

Single

Separated

Divorced

Widowed

Re-Married

Income *

$0 - $40,000

$41,000 - $60,000

$61,000 - $80,000

$80,000+

Referred by *

Self

Police

Medical/Doctor

Friend/Family

Other

Today's date *

MM

DD

YYYY