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Summer Session Enrollment Form

CHILD'S INFORMATION

Child's Birthday
Month
Day
Year
School Type
Please check the boxes to indicate your child's favorite subjects (check all that apply)
How did you hear about us?
Does your child have any allergies, medical conditions, or an IEP/504?
Yes
No

PARENT/GUARDIAN INFORMATION

Is your home address the same as the child's as listed above?
Yes
No

OTHER PARENT(S)/GUARDIANS

Does this person have permission to pick up your child?
Yes
No
Does this person have permission to pick up your child?
Yes
No

PERMISSIONS

Please list the name of any adults who may bring your child to sessions and who have permission to pick up your child

EMERGENCY/ALTERNATE CONTACTS

Who do we have permission to contact regarding your child if you are unable to be reached?

One Time Registration Fee
$30

I certify that the above information is true and accurate.

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