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Virtual Summer Preschool Program Registration
Held virtually on Tuesdays and Thursdays
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* Indicates required question
Email address
*
Your answer
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Date of Birth (child must be 2 1/2 years old by Sept 1, 2020, fully potty-trained and able to self-care)
*
MM
/
DD
/
YYYY
Gender
*
Choose
Male
Female
Social Security Number
Your answer
Student's Street Address
*
Your answer
Student's Zip Code
*
Your answer
Parent's First Name
*
Your answer
Parent's Last Name
*
Your answer
Parent's Street Address
*
If different than student's
Your answer
Parent's Zip Code
*
If different than student's
Your answer
Parent's Home Phone
*
Your answer
Parent's Cell Phone
*
Your answer
Current School
Your answer
Special Needs
Your answer
How did you find out about our program?
*
Choose
Student
Congregation member
Jax4Kids website
JaxMomsBlog website
Other advertising
Referral
Other
Completed by
*
Type your full name
Your answer
Your relationship to the student
*
Your answer
Date form completed.
*
MM
/
DD
/
YYYY
Submit
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