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After School Program Registration
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After School Program Registration
After-School Program
Child's Name
*
First
Last
Gender
*
Male
Female
Date of Birth
*
Date Format: MM slash DD slash YYYY
Student's Age
*
Please enter a number from
0
to
100
.
Student's School
*
Name of Parent(s) /Guardian(s)
*
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Home Phone
*
Cell Phone
*
Work Phone
*
Note: If any of the above information changes, please notify us immediately.
EMERGENCY CONTACT INFORMATION
List two emergency contacts other than those listed above
Contact #1
*
Contact #2
*