JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Registration for the 2021-22 "Little Raiders" Child Development Program
Keyport High School
351 Broad Street
Keyport, NJ 07735
Ms. Racioppi
dracioppi@kpsdschools.org
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Little Raiders Student Registration Form
Student Information for the 2021-22 School Year
First Name of student
*
Your answer
Last Name of student
*
Your answer
Age on October 1st 2021
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Home Address
*
Your answer
Current/other school experience & where:
*
Your answer
FAMILY INFORMATION
Guardian 1 Last name, first
*
Your answer
Guardian 1 Cell Phone
*
Your answer
Guardian 1 Address
*
Your answer
Guardian 1 Email
*
Your answer
Guardian 2 Last name, first
*
Your answer
Guardian 2 Cell Phone
*
Your answer
Guardian 2 Address
*
Your answer
Guardian 2 Email
*
Your answer
General Information
Siblings First Names and Ages
*
Your answer
Medical Concerns or learning issues that I should be aware of?
*
Your answer
Does you child have allergies?
*
Yes
No
Option 3
Other:
How did you hear about the program?
*
Your answer
What are your child's favorite toys? Or things to play with?
*
Your answer
What other organized activities is your child involved in (soccer, gymnastics, preschool, etc. )?
*
Your answer
Has your child had opportunities to play/interact with other children?
*
Your answer
Please send immunization records to: Keyport High School, Attn. Dawn Racioppi, 351 Broad Street, Keyport, NJ, 07735
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Keyport School District.
Report Abuse
Forms
