Registration

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Parent Information

Name *

First Name

Last Name

Address *

Address1

Address 2

City

State

Zip

Home Phone *

Area Code

Phone First 3

Phone Last 4

Mobile Phone

Area Code

Phone First 3

Phone Last 4

Work Phone

Area Code

Phone First 3

Phone Last 4

Emergency Contact Name

Emergency Contact Number

Area Code

Phone First 3

Phone Last 4

E-mail *

Repeat e-mail *

Password *

Repeat Password *

6 characters and contain at least one uppercase letter, number, or symbol

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Child Information

Name *

First Name

Last Name

Gender*

Birthdate *

Class Coordinator (if applicable)

School Currently Attending

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