Pearls Registration Form

Emergency Contact
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Physician and Medical Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Preferred Hospital
Insurance/Health Coverage (Company)
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns. If none, put N/A

Child 1 Information
Name

First NameLast Name
Birthday

MonthDayYear
Date
Gender
Grade
Which semester are you registering for?
Has your child previously attended Pearls of Hope? If so, which year(s)? If no, place N/A
Child 2 Information

Please fill out the information for the second child that you are registering.
Name

First NameLast Name
Birthday

MonthDayYear
Date
Gender
Grade
Which semester are you registering for?
Has your child previously attended Pearls of Hope? If so, which year(s)?
Child 3 Information

Please fill out the information for the third child that you are registering.
Name

First NameLast Name
Birthday

MonthDayYear
Date
Gender
Grade
Which semester are you registering for?
Has your child previously attended Pearls of Hope? If so, which year(s)?
Child 4 Information

Please fill out the information for the Forth child that you are registering. If you have a 5th child or more, contact admin.
Name

First NameLast Name
Birthday

MonthDayYear
Date
Gender
Grade
Which semester are you registering for?
Has your child previously attended Pearls of Hope? If so, which year(s)?

One Child Fee

$50.00 Quantity

Two Children Fee

$90.00 Quantity

Three Children Fee

$130.00 Quantity

Four Children or more Fee

$150.00 Quantity

Total

Emergency Contact