Aanmelding - De Koggepurkies

EN | NL

Registration for De Koggepurkies

Requested childcare

Welkom bij De Koggepurkies! In dit formulier kunt u uw (ongeboren) kind aanmelden.

Startdate*

Remark

Child

You will be able to register another child after submitting the first registration

Initials
First name*
Last name prefix
Last name*

Date of birth*
Estimated date of birth / Not yet born
Gender*

Medical notes
May be picked-up by

Parent/Guardian 1 (Who will receive the invoices)

Title
Initials*
Firstname*
Last name prefix
Last name*
Relationship
Date of birth*
Streetname*
House number*
House number extension
Postalcode (numbers)*
Postalcode (characters)*
City*
Country
Mobile phone number*
Phonenumber (work)
E-mail address*
BIC/SWIFT code (if applicable)

Parent/Guardian 2

Title
Initials
Firstname
Last name prefix
Last name
Relationship
Date of birth
If you do not enter an address here, the address of parent/guardian 1 will be automatically taken over.
Streetname
House number
House number extension
Postalcode (numbers)
Postalcode (characters)
City
Country
Mobile phone number
Phonenumber (work)
BIC/SWIFT code (if applicable)

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