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Registration
Please read all questions thoroughly and answer them as accurately as possible.
* Indicates required question
Email
*
Your email
Parent/Guardian Information
Parent/Guardian FULL Name
*
Your answer
Primary Phone Number
*
Your answer
2nd Parent/Guardian FULL Name
*
Your answer
Secondary Phone Number
*
Your answer
Secondary Email
*
Your answer
Emergency Contact Name
*
Needs to be other than yourself or parent/guardian 2
Your answer
Relation to Child(ren)
*
Needs to be other than yourself or parent/guardian 2
Your answer
Emergency Contact Phone Number
*
Needs to be other than yourself or parent/guardian 2
Your answer
Please list the FULL names of any other adults you approve to pick-up your child(ren) from our classes
*
Your answer
Is your family currently enrolled in our after school Youth Mentorship Program?
*
Yes
No
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