Register A Child 
Please read the following guidelines before filling out this form. Incomplete Submissions will not be accepted.  First and Last names are required for guardians and all children. P.O. Box not accepted. If we cannot reach you through the email address you provided, your form will not be processed. Thank you.
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Email *
Parent/Guardian Full Name *
Address (P.O. Box not accepted) *
City *
State *
Zip Code *
Phone Number *
Do you receive government assistance such as SSI, SNAP,  or Medicaid? *
Number of people in household? *
Child Name *
Child Date of Birth *
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Child Diagnosis *
Additional Child Name
Additional Child Date of Birth
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Additional Child Diagnosis
Additional Child Name
Additional Child Date of Birth
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YYYY
Additional Child Diagnosis
Additional Child Name
Additional Child Date of Birth
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DD
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YYYY
Additional Child Diagnosis
Additional Child Date of Birth
MM
/
DD
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YYYY
Additional Child Diagnosis
Additional Child Name
Are you interested in enrolling your child in our TechArt Innovators Club, where they will learn graphic and web design? (for ages 16-25) *
Are you interested in enrolling your child in our Artistic Adventures Summer Program?  *
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