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Neighborhood Center at Southmoor Spring Enrichment Registration Form
Please complete this form to register for Southmoor's Spring Enrichment session.
Student's First Name *
Your answer
Student's Last Name *
Your answer
Student's Grade & Teacher *
Example: (1st / Johnson)
Your answer
Student ID Number
Your answer
Student's Birth Date *
MM/DD/YYYY
Your answer
Parent/Guardian Name(s) *
Your answer
Parent/Guardian Email(s) *
Your answer
Parent/Guardian Contact Number(s) *
Example: (123)456-7890
Your answer
Emergency Contact/Authorized for Pick-Up *
Example: John Smith, (123)456-7890
Your answer
Emergency Contact/Authorized for Pick-Up
Example: Jane Smith, (123)456-7890
Your answer
How will your child be leaving the program? *
Please check all that apply:
Required
I give my child permission to appear in any media coverage approved by Neighborhood Center staff. *
Are there any activities your child CANNOT participate in due to physical, social, or religious reasons? *
Please answer yes or no. If yes, please explain.
Your answer
Does your child require any special arrangements, have special needs, or have any allergies? *
Please answer yes or no. If yes, please explain.
Your answer
Will your child need to take any medication during the enrichment program? *
Please answer yes or no. If yes, please explain.
Your answer
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