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STEM4kids - After School Program 2023-2024
Registration Form
* Indicates required question
Email
*
Your email
Parent/Guardian Information
Mother/Guardian First and Last Name
*
Your answer
Mother/Guardian Address
*
Your answer
Mother/Guardian Email Address
*
Your answer
Mother/Guardian Home Phone
Your answer
Mother/Guardian Cell Phone
*
Your answer
Mother/Guardian Work Phone
Your answer
Father/Guardian First and Last Name
*
Your answer
Father/Guardian Address
*
Your answer
Father/Guardian Email Address
*
Your answer
Father/Guardian Home Phone
Your answer
Father/Guardian Cell Phone
*
Your answer
Father/Guardian Work Phone
Your answer
Emergency Contacts:
First Contact Name
*
Your answer
First Contact Phone Number
*
Your answer
First Contact Relationship
*
Your answer
Second Contact Name
Your answer
Second Contact Phone Number
Your answer
Second Contact Relationship
Your answer
List all individuals authorized to pick up your child (other than child’s parents). Unlisted persons will not be permitted to pick up our child. Identification may be requested from listed individuals.
First Contact Name
*
Your answer
First Contact Phone Number
*
Your answer
First Contact Relationship
*
Your answer
Second Contact Name
Your answer
Second Contact Phone Number
Your answer
Second Contact Relationship
Your answer
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