Course Registration Form

Pack 459 NEW Scout Registration

2019-20 School Year
Student Name*

First NameMiddle NameLast Name
Preferred Nickname
Birth Date

MonthDayYear
Gender*
Grade*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Number*

Area CodePhone Number
Parent #1 Name*

First NameLast Name
Gender*
Parent #1 E-mail*
Parent #1 Mobile Number

Area CodePhone Number
Parent #1 Address (if different than child)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent #2 Name

First NameLast Name
Gender
Parent #2 E-mail
example@example.com
Parent #2 Mobile Number

Area CodePhone Number
Additional Comments

My Products

Kindergarten through 4th Grade$94.00

5th Grade$75.00

Enter coupon

Total $0.00

Credit Card

email hazelkkim@gmail.com with any questions or concerns
Should be Empty: