* Child's Name:

* Date of Birth:
(MM/DD/YYYY)

* Parent's Names:

Parent's Names:

* Parent's Address:

* City:

State:
AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA MD ME MA MI MN MS MO MT ME NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

* Daytime phone: (starting with area code)
-

* Email Address:

Grandparent's Names:

Grandparent's Names:

Name of person providing information:
(if different from above)

Relationship to child:

Address:

City:

State:
AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA MD ME MA MI MN MS MO MT ME NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Phone: (starting with area code)
-

Email Address:

Fees:

• $17 for one child
• Total for photo: $
• Upon receipt, The Janesville Gazette will contact you to process a credit card payment. The Gazette accepts VISA and Mastercard.

Order additional copies now for $1 each!

• I would like to order copies     Total for copies: $
• Copies can be picked up at The Janesville Gazette, 1 S. Parker Drive, Janesville between April 20 and April 30.
• Office hours are 8 a.m.-5 p.m. Monday-Friday.

Total due: $

Photo restrictions:

• Only one photo per form
• Only one child per photo
• Close-up, color photos suggested
• No photos larger than 1200 pixels x 1800 pixels at 300 dpi
• Photos must be in jpg format, no larger than 5 MB

If you're not a Gazette subscriber, would you be interested in receiving information about Gazette home delivery specials offers? Yes

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Problems or questions? Call 608-741-6651 if you have problems or have questions regarding Cute Kids.