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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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