Father Figure Academy Registration Form

Registration Form
Student Name

First NameLast Name
Birth Date

MonthDayYear
Gender

BoyGirl
Mother's Name

First NameLast Name
E-mail
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Name

First NameLast Name
E-mail
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of the person we should call incase of emergency

First NameLast Name
E-mail
example@example.com
Phone Number
How soon are you ready to start

1 - 4 weeks1 - 3 months3 - 6 months
Who has parental responsibilities

1 - 4 weeks1 - 3 months3 - 6 months
foods allergies
Personality

ShyLoudActivefunnyCalm
Caregiver Signature

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Parent Signature

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Should be Empty: