Form - Registration

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ABOUT US
OUR TEAM
CONTACT US
FRIDAY PROGRAM
SHOP
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FAMILY
STAFF

HOME
ABOUT US
OUR TEAM
CONTACT US
FRIDAY PROGRAM
SHOP
GIVE
FAMILY
STAFF

Registration Form

Free Text

Once the form is completed you will recieve a copy via email.

What Program are you registering For:

Mindset Fridays

5 Day Program

Student Information

Student Infromation

Student Name:

Date of Birth:

Special Needs

Home Address

City

State:

ZIP:

Medical Information

Medical Information

Does your child have a life-threatening condition?

Yes

No

If yes, please explain:

Does your child need medication at school?

Yes

No

If yes, please explain:

Does your child have any other medical issues of which we need to be aware?

Yes

No

If yes, please explain:

Food Allergies:

Yes

No

If yes, list known allergies.

Parent or Guardian Contact Information

Parent or Guardian Contact Information

Guardian Name 1:

Relationship to student:

Phone #:

Email:

Guardian Name 2:

Relationship to Student

Phone #:

Email:

Emergency Contact

Emergency contact Information

Emergency contact name:

Phone #:

Upload Parent DL

Upload a photo or scan of the front of your DL

Thank you for your submission.

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Member

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