PARENT
REGISTRATION FORM

Step 1

English

Spanish

PARENT INFORMATION

First Name*

Last Name*

Phone Number *

Alternate Phone Number

Language Spoken*

Home Address*

Gender*

DOB*

Program Code

STUDENT INFORMATION

Student 1

First Name*

Last Name*

District*

School*

Grade*

Student 2

First Name

Last Name

District

School

Grade

Student 3

First Name

Last Name

District

School

Grade

LOCAL EMERGENCY CONTACT

First Name*

Last Name*

Relationship*

Phone Number(s) *

Step 2

English

Spanish

PROGRAM PREFERENCES

Please Select Your Program Preference*

In Person

Virtual

Either

Please Select Your Schedule Preference.*

Morning

Evening

Either

PHOTO RELEASE AUTHORIZATION

I Give Permission For My Photo To Be Taken For Promotional Materials.*

YES

Step 3

English

Spanish

ADDITIONAL INFORMATION

Please Select The Highest Level Of Education You Have Received.

Please Provide Any Additional Information That Would Help Us Provide You With The Best Support.

signature *

Date*

7, December 2023

PARENT REGISTRATION FORM

Step 1

PARENT INFORMATION

STUDENT INFORMATION

Student 1

Student 2

Student 3

LOCAL EMERGENCY CONTACT

Step 2

PROGRAM PREFERENCES

PHOTO RELEASE AUTHORIZATION

Step 3

ADDITIONAL INFORMATION

Please Select The Highest Level Of Education You Have Received.

Please Provide Any Additional Information That Would Help Us Provide You With The Best Support.

signature *

Date*

PARENT
REGISTRATION FORM