Jump Start 19-20
My child will be attending Jump Start the week of August 19-23, from 9:00 am to 12:00 pm. *
My child will attend Jump Start the following days-check all that apply *
Required
Student's First and Last Name *
Your answer
Student Birthdate *
MM
/
DD
/
YYYY
Has your child attended preschool? *
Name of school/program your child attended. *
Your answer
Name of Primary Contact *
Your answer
Primary Contact Email *
Your answer
Primary Contact Phone Number *
Your answer
Primary Home Address *
Your answer
Name of Secondary Contact
Your answer
Secondary Contact Email
Your answer
Secondary Contact Phone Number
Your answer
Secondary Home Address
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Email *
Your answer
Emergency Contact Phone Number *
Your answer
Does your child have health concerns you would like us to know about? *
Your answer
Does your child have any allergies? If yes, please list them and any medications used. *
Your answer
Is there any other information you would like to share about your child? *
Your answer
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