City of Victoria Form Center

2. Caregiver's First Name*
3. Caregiver's Last Name*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
13. Email Address*
15. Child's First Name*
16. Child's Last Name*
18. Child's First Name
19. Child's Last Name
21. Waiver & Release Confirmation *

    1. I agree
    2. I do not agree

    By checking the box above, you have acknowledged and agreed to the two forms attached, Photo Release Waiver and Fire & Ice Release.

Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field