Student Registration Form

Education Through Athletics

1125 Lena St. NW

Atlanta, GA 30314

edthruathletics@gmail.com

www.edthruatl.org

(770) 861-6196
Student Registration Form
- Parent's Full Name
  
  First NameMiddle NameLast Name
- Child's Full Name
  
  First NameMiddle NameLast Name
- Age
  e.g. 11183021
- Grade Level
  for Incoming A.Y. '12-'13
- Email
- Phone Number
  Format: (000) 000-0000.
- Birth Date
  
  MonthDayYear
- Present Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Emergency Contact
  
  First NameLast Name
- Relationship
  ex. Father, Mother, etc.
- Phone Number Of Person To Contact In Case Of Emergency
  Please enter a valid phone number.Format: (000) 000-0000.
- Email Of Person To Contact In Case Of Emergency
  example@example.com
- Current School Attending
- Allergies to (if any):
- Medical Information:
  
  Other
- How do you plan to pay the registration fee?
- Suggestions / Comments
- I consent to my child participating in the Education Through Athletics After-School Program for the 2025/2026 school year.
- Please verify that you are human
- Should be Empty: