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Shelley's House Scholar Registration Form

Thank you for your interest in enrolling your child in Shelley’s House! 

Our organization provides holistic wellness programs, mentorship, and community support for youth.

Please complete this form to provide us with the necessary details about your child. 

If you have any questions, feel free to contact us at 

info@shelleyshouse.org and shelleyshouse56@gmail.com or 443-857-7356

Email *
Visit our site www.shelleyshouse.org
Parent/Guardian information 
Full Name
 *
Phone Number *
Email Address *
Home Address *
Preferred Contact Method *
Required
Scholars' (child) information
Full Name
 *
Date of Birth  *
MM
/
DD
/
YYYY
Scholars' (child) Age *
Scholars' (child) Gender Identity (OPTIONAL)
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Does your scholar (child) have any allergies, medical conditions, or specific needs we should be aware of? *
What school does your scholar (child) attend? *
What grade is your scholar (child) in?  *
How did you hear about Shelley's House *
Which of the following programs interest you and your child *
Required
Does your child currently receive therapy? *
Would you be interested in parent workshops or family support groups? *
Emergency Contact information  *
Relationship to scholar (child)? *
Consent & Agreement: I give permission for Shelley's House to take photos/videos of my child for program documentation and promotional purposes. *
Liability Waiver: I understand that Shelley’s House and its staff are not liable for any injuries or incidents that may occur during participation in programs. (Checkbox Agreement) *
Required
Parent Guardian electronic signature *
Submit
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