Student Registration

Parent/Guardian Name*

First Last

Parent/Guardian Email Address*

Parent/Guardian Phone*

The best way to reach me is*

Where or from whom did you hear about this opportunity?*

Please list the names and phone numbers of all the people who have your consent to pick up your student:*

What other contact information do we need, if any? (List names with phone numbers)*

Student Name*

First Last

Student Address*

Street Address Address Line 2 City State ZIP Code

Upload Student Photo

Upload photo as jpg, png, or pdf

Accepted file types: jpg, png, pdf, jpeg, webp, Max. file size: 10 MB.

Student's Birthday:*

Please list any medications, medical issues, and/or health concerns your student has that we should be aware of.*

Location I want to register my student for:*

Does your student have transportation or a way to and from the location you chose?*

Yes

No

Does your student have permission to leave this campus by himself/herself at dismissal?*

Yes

No