PLEASE COMPLETE THE FORM BELOW. PLEASE COMPLETE ONE FORM PER CHILD.

^* These fields are required.

First Name: ^*

Last Name: ^*

Returning PT Participant: ^*

Phone: ^*

Street Address: ^*

City: ^*

State/Province: ^*

Zip: ^*

Birthdate (MM/DD/YYYY): ^*

Participant Age Group: ^*

Gender: ^*

School: ^*

Grade (as of coming Fall semester): ^*

Ethnicity: ^*

Race: ^*

Primary Language: ^*

Child qualifies for gov't assistance or free/reduced lunch program: ^*

Household Monthly Income ( 1500.00 format, no $ and no comma): ^*

Number of members in household: ^*

Parent/Guardian First Name: ^*

Parent/Guardian Last Name: ^*

Parent/Guardian Email:

Parent/Guardian Phone: ^*

Phone Type: ^*

How does the child leave school?: ^*

List names of adults, other than parent or guardian, who have permission to pick up this child: ^*

Emergency Contact 1: ^*

Emergency Contact 1 Relation: ^*

Emergency Contact 1 Email:

Emergency Contact 1 Mobile Phone: ^*

Emergency Contact 1 Home Phone:

Emergency Contact 2: ^*

Emergency Contact 2 Relation: ^*

Emergency Contact 2 Email:

Emergency Contact 2 Mobile Phone: ^*

Emergency Contact 2 Home Phone:

Medical Information: ^*

Food Allergies: ^*

Food Allergy Details:

Medicine Allergies: ^*

Medicine Allergy Details:

Program Location: ^*

Registration Fee Paid: ^*

Participant PTDID (6 digits include leading zeros):

PLEASE COMPLETE THE FORM BELOW. PLEASE COMPLETE ONE FORM PER CHILD.

ABOUT US

HOW IT WORKS

OUR PROGRAMS

GET INVOLVED

PLEASE COMPLETE THE FORM BELOW. PLEASE COMPLETE ONE FORM PER CHILD.

ABOUT US

HOW IT WORKS

OUR PROGRAMS

GET INVOLVED

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