Education Enrichment Program Event Registration

 
Please complete the form below. Be sure to specify the name of the education event(s) or program(s). You may register your child for more than one event on the same form. If you want to register more than one child, please fill out a separate form for each child.
 
 
Education event or program name
 
Participant full name child or adult
 
Parent name if child participant
 
Street address with city state zip
 
Participant grade completed by the end of this school year
 
Participant date of birth
 
Participant email address
 
Work phone number
 
Cell phone number
 
Home phone number
 
Emergency contact name phone
 
 
 
Participant brief health history
 
 
 
Participant food allergies
 
Electronic signature and date