Course Registration Form

Pack 459 NEW Scout Registration

2019-20 School Year
Student Name *

First Name Middle Name Last Name
Preferred Nickname
Birth Date

Month Day Year
Gender *
Grade *
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Number *

Area Code Phone Number
Parent #1 Name *

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

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

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent #2 Name

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

Area Code Phone 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
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