After School Club registration
Todays Date:
-
Month
-
Day
Year
Date
Name of participent
First Name
Last Name
Name of Guardian
First Name
Last Name
Email
example@example.com
Contact Number for Guardian
Please enter a valid phone number.
What Club would you like to sign up for?
Please Select
Lego Club
Arts and Crafts Club
both
Date
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Information about participant
physical aggression
ability to communicate needs
toilet trained
elopement concerns
Any additional information that you feel is important for us to know: alergies, diagnosis, likes/dislikes, things that help your individual calm, things that might be a trigger.
My Products
*
prev
next
( X )
club registration
Click how many club days you are registered for at this time.
$
25.00
Quantity
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and
submit
the form.
Submit
Should be Empty: