Ready to Sign Up for 5th Day?
We are excited to have you! Please give us a few details and you will be placed on the 5th Day registration list for School Year 2019-20. [All your information will remain strictly confidential.]
What is the student's first name? *
Your answer
What is the student's last name? *
Your answer
What is the student's date of birth? [Please use this format: mm/dd/yyyy] *
MM
/
DD
/
YYYY
What is the student's gender? *
Required
What grade is student entering in Fall 2019? *
What school will the student attend for 5th Day? *
What is the parent/guardian's first name? *
Your answer
What is the parent/guardian's last name? *
Your answer
What is your current address? *
Your answer
City? *
Your answer
State? *
Your answer
Zip Code? *
Your answer
Please provide a parent/guardian contact phone number. [use this format: xxx-xxx-xxxx] *
Your answer
Please provide a parent/guardian email address. *
Your answer
What is the student's Primary Language? *
What is the student's Ethnicity? *
What is the student's Race? *
Required
Do you have a particular question that needs an answer?
Your answer
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