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admission slip
Home
Programs
Donate
Donate
Merch
Contribution
About
Our Vision
Contact
Events
admission slip
REGISTER HERE
Child's Name
*
First Name
Last Name
D.O.B.
*
MM
DD
YYYY
Ethnicity
*
Black
White
Hispanic/ Latino
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Two or more
Other
Name of School
*
Grade
*
Gender
*
Male
Female
I choose not to disclose
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Choose a Program
*
Lessons of Value
Morals of the Game
Hands in the Kitchen
Imaginary Friends
WealthWave & Wellness
Creative Arts
Any food allergies we should know of
*
CONTACTS
MOTHER
*
First Name
Last Name
Phone
(###)
###
####
FATHER
*
First Name
Last Name
Phone
(###)
###
####
Contact#1
*
In case of Emergency
First Name
Last Name
Contact#2
*
(In Case of Emergency)
First Name
Last Name
( If Applicable) My Child May not be released to the following individual(s) (if parent of child restraining order must be on file)
Primary Language Spoken
English
Spanish
Other
Medical Information
Physician, Physcian's #, Policy #, Health Issues, Medications.
Thank you!
