Summer Registration
Program Dates: May 28th - July 26th | Monday - Friday 9am - 6pm
Information of Child
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Student's Race
School Student Attends
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Female
Male
Grade of Student
6th
7th
8th
9th
10th
11th
12th
Other
Is Student New or Returning?
New
Returning
Information of Parent/Guardian
Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Emergency Contact 1
In the event of an emergency, please contact:
Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Medical Information
Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.
Preferred hospital
Insurance/health coverage
Next Up Summer Program Fee
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Next Up Summer Program Fee
Fee for each student that will be attending the Next Up Summer Program
$
100.00
Credit Card
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