Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
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Emergency Contact Information
Name
*
First Name
Last Name
Relationship
*
Email
*
example@example.com
Home Phone
*
-
Area Code
Phone Number
Mobile Phone
-
Area Code
Phone Number
Business Phone
-
Area Code
Phone Number
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Further Information
Please describe your personality, interests, strengths, and dislikes.
*
Please describe any specific needs.
*
For what purpose are you enrolling your child? Please provide as much detail as possible. (Required)
*
Are you involved in any other agencies? If so, Which agencies and for what purpose?
Available times
Please indicate the weekday and time you would be available to attend.
Weekdays
*
Monday
Tuesday
Wednesday
Thursday
Friday
Times
*
Mornings
Afternoons
Late afternoons
Any additional comments about availablility:
Is there anything else you would like us to know about you or your family?
*
Please list the people that are approved to pick up / drop off the participant:
*
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Should be Empty: