Registration Form

Registration Form

Date: June 15 & 16 | Time: Gr 3-5, 4:00-5:00PM & Gr 6-8, 5:30-7:00PM | Location: Lifeline 2721 Prairie Street Elkhart | Cost: $25 per child
Parent Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Student Name

First NameLast Name
Grade
Grade
School
School
Gender
Should be Empty: