Program Registration
Student Name
*
First Name
Last Name
Student Primary Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Program Location
*
Please Select
EN-RICH-MENT
One Center
Patrick Elementary School
School District
*
Name of School
*
Grade in School
*
Student Date of Birth
*
-
Month
-
Day
Year
Date
Student Age
*
Ethnicity
*
Asian or Pacific Islander
American Indian or Alaska Native
Black or African American
Hispanic
White
Other
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Relationship to Student
*
Parent/Guardian Email
*
Same email used for your Academy application
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Parent/Guardian Emergency Phone Number
*
Please enter a valid phone number.
Alternate Emergency Contact
*
Alternate Emergency Contact Phone
*
Please enter a valid phone number.
Alternate Emergency Contact Address
*
Does your student have any medical conditions or special needs we should be made aware of?
*
Student's Primary Care Physician Name and Address
*
Student Primary Care Physician Phone
*
Please enter a valid phone number.
Student T-Shirt Size
*
Please Select
(Choose One)
Youth Small
Youth Medium
Youth Large
Ladies Small
Ladies Medium
Ladies Large
Ladies X-Large
Student Email
Optional-By submitting this form, you give us permission to communicate with your registrant by email if this field is populated.
Student Mobile Phone Number
Optional -By submitting this form, you give us permission to communicate with your registrant by text if this field is populated.
Head Shot Upload
*
Browse Files
Drag and drop files here
Choose a file
Please upload a head shot of your registrant for check-in/check-out.
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