subject_line
Student Registration
Student First Name
*
Student First Name
*
Address
*
City and Zip
*
Student Phone # (if applicable)
*
Student Email Address (if applicable)
*
Birth Date (mm/dd/yr)
*
Grade
*
1
2
3
4
5
6
7
8
9
10
11
12
Gender
*
How did you hear about us?
*
Google
Yelp
Facebook
Word of Mouth
Referral
Referral
Select
your program:
*
Day Program
Summer Program
After School Tutoring
Friday Intervention
Current or Previous School Information (Name, Address, City & Zip)
*
Parent Name (Primary Contact)
*
Billing Address, City and Zip
*
Best Contact #
*
Email Address
*
Employer?
*
Work #
*
Parent Name (Secondary Contact)
*
Best Contact #
*
Email Address
*
Employer?
*
Work #
*
Emergency Contact
*
Relationship to Student
*
Best Contact #
*
Email Address
*
Doctor's Name
*
Phone #
*
Dentist's Name
*
Phone #
*
Hospital Preference
*
Allergy Information
*
Medical Information
*
Prescribed Medication
*
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