2018-2019 SHINE Registration
Child's First Name *
Your answer
Child's Last Name *
Your answer
Birthday *
MM
/
DD
/
YYYY
Gender *
Shirt Size *
Current Grade *
School *
Your answer
Child's home mailing address *
Your answer
Child's home phone number *
Your answer
Parent #1 name *
Your answer
Parent #1 cell *
Your answer
Parent #1 email address *
Your answer
Parent #2 name
Your answer
Parent #2 cell
Your answer
Parent #2 email
Your answer
Emergency contact name, relationship and cell *
Your answer
Child lives with *
Parents are *
Provide a secondary mailing address if applicable
Your answer
Food Allergies? *
Food Allergy - If none, type NONE or NA *
Your answer
List any medicines or special requirements or NA *
Your answer
Medical Provider *
Your answer
Medical Provider Phone *
Your answer
Insurance Company *
Your answer
Group / Policy Insurance Number *
Your answer
Does your child attend ECC? *
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