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2017 Summer Program Request Form
This form indicates your interest in one of our Summer Programs for 2017.

Please visit our Early Childhood website at: for information on our summer programs and the registration process prior to completing this form.

Please complete one Program Request Form per child.
Deadline during Registration process is Thursday, March 23, 2017.
Forms received after this deadline will be processed when space becomes available.

If you have any questions, please email us at

Our office staff will contact you regarding the registration process once placement is confirmed.

Child Legal Last Name
Your answer
Child Legal First Name
Your answer
Child Birth Date
Child Gender
Street Address (where child resides)
Your answer
Your answer
State, Zip Code
Your answer
Child Current Grade in 2016-2017 School Year
Current School
Contact First Name
Your answer
Contact Last Name
Your answer
Contact Cell Phone
Your answer
Alternate daytime phone
Your answer
Contact Email
Your answer
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