2023 Program Registration                              *FORM TO BE COMLETED BY THE LEGAL GUARDIAN ONLY!
Please complete this form for the 2023 program registration.  Each program participant will receive an individualized schedule according to the programs selected.  

THERE WILL BE A MANDATORY ORIENTATION

Please visit our website for more information about programs & services
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Email *
This is for program sponsors only.  Skip if you are only registering for programs
SPONSORS-Please include:
*Your Name
*Email or phone number
*Type of sponsorship: 
(A):$40 (5 programs)
(B):$80 (10 programs)
(C):$120 (15 programs)
(D):$160 (20 programs)
Name of parent/guardian *
Relationship to child *
Parent/guardian's phone number & email address *
Address where child lives more than 50% of the time *
Child's name *
Child's age *
Child's school *
Program interest- Circle of Dreams *
Required
Additional programming at the center
Clear selection
MANDATORY ORIENTATION 
Date To Be Announced 
4704 Leiper Street, Philadelphia, PA 19124
Wheelchair accessible (5-step ramp)/Free parking
 
What day & time work better for you after 6PM?
 *
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