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Explora Registration, Fall 2019
Tuesdays 5-7pm; Girls Who Code
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Email
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Your email
Student's full name
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Your answer
Birthdate
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MM
/
DD
/
YYYY
Age (Min 6th grade or 10 years old)
*
Your answer
Student's email address
Your answer
Student's phone number
Your answer
Allergies and medical conditions
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Your answer
Guardian 1 full name
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Your answer
Guardian 1 phone number
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Your answer
Guardian 1 relation
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Father
Mother
Legal Guardian
Power of Attorney
Other
If Other, please specify
Your answer
Guardian 2 full name
Your answer
Guardian 2 email address
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Guardian 2 phone number
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Guardian 2 relation
Choose
Father
Mother
Legal Guardian
Power of Attorney
Other
If Other, please specify
Your answer
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