FLRC Summer Lunch Program
Making Sure No Child Goes Hungry This Summer
General Information
Student Name
First Name
Middle Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Birth Date
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January
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Month
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Day
Please select a year
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Year
Gender
Please Select
Prefer Not To Answer
Female
Male
Gender Neutral
Other
School Name
Mableton Elem
Grade
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Residence Information
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/ Guardian Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Emergency Contact Information
Primary Emergency | Contact Name
First Name
Last Name
Primary Emergency | Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Emergency | What is your relationship with this person?
We will be attending Books and Bites With Mayor Michael Owens on July 30th
YES
NO
Parent Authorization
I certify that the information provided is true and accurate and authorize my child(ren) to participate in the Family Life Restoration Center, Inc. Summer Lunch Program. My child may pick up food items for their consumption. I hold Family Life Restoration Center, Inc., its staff, volunteers and board of directors harmless for any food consumed by me and my family.
Signature
Photo & Media Release: FLRC is authorized to use photographs/video of my child for program promotion and reporting.
Please Select
YES
NO
If there is any other information that you think would be useful to share, please specify.
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