Student Registration Form

The Community Care Learning Foundation Student Registration
Please complete the following information to register your student to be considered for enrollment in our program.
STUDENT INFORMATION:
Student Name *

First Name Last Name
Current School Grade Level *
Date of Birth *

Month Day Year
School Name *
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name *

First Name Last Name
E-mail *
example@example.com
Phone Number *
Mailing Address (if different)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
SIGNATURE
I agree that I am voluntarily providing information about my student. *

Check to confirm your agreement.
Parent/Guardian Print Name *

First Name Last Name
Parent/Guardian Signature *

Clear
Date Signed *

Month Day Year
Date
If you have any questions about this form or our program, please call (686) 226-6526 or email thecclfoundation@jamesdeshay.com.
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The Community Care Learning Foundation Student Registration