Reading Readiness and Motivational Mathematics Afterschool/Tutoring Registration

Reading Readiness and Motivational Mathematics Afterschool/Tutoring Registration

Starting: September 1st M-W 3:45pm-5pm
CHILD INFORMATION:
Child Name

First NameLast Name
Birth Date

MonthDayYear
Grade
Age
Behavioral Issues/Concerns
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
MEDICAL INFORMATION
Physician Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Please list any Allergies or other Medical Issues we should be aware of.
Type N/A or NONE if there are no medical issues.
Emergency Contact

Please list 2 emergency contacts in the case that you are unable to be reached.
Emergency Contact #1

First NameLast Name
Emergency Contact #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2

First NameLast Name
Emergency Contact #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do we have permission to call 911 for your child in the case of an emergency?
Should be Empty:

Emergency Contact