Power Program Registration
Program
*
Please Select
PowerSproutz (ages 2-3)
PowerTotz (ages 4-6)
PowerKidz I (ages 7-9)
PowerKidz II (ages 10-12)
Session
*
Please Select
Fall Session 10/2 to 12/11
PowerKidz Day
*
Please Select
Wednesday
Thursday
Participant Name
*
First Name
Middle Name
Last Name
Participant Birth Date
*
-
Month
-
Day
Year
Date
Parent or Guardian Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Emergency Contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Medical History / Allergies / Special Instructions
Please verify that you are human
*
Submit
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