Child's Name (one child per form please)
*
First Name
Last Name
Grade as of September 2025
*
9th
10th
11th
12th
School District
Parent/Guardian's Name
*
First Name
Last Name
Parent/Guardian's Email
*
example@example.com
Parent/Guardian's Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Information
*
Name
*
Relationship to child
*
Best number to call in an emergency
Please list the name, phone number and relationship, of those allowed to pick up your child.
*
Registration
*
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Connecting Mind and Body
Mondays, July 14th - August 18th, 3:30pm - 4:30pm
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