Scratch Sessions South Registration
Please fill out registration/contact form for 2017 fall sessions
Student Information
Student(s) Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender
Current School(s) *
Your answer
Ethnicity *
Allergies (if any)
Your answer
Special health or behavioral notes (if any)
Your answer
Which sessions will the student be attending
(come to as many as you can)
Parent/Guardian Information
If student is under 18 years of age.
Name, Relationship to student(s)
Your answer
Home Address (Street, City, State, Zip Code)
Your answer
Phone Number *
Your answer
Email *
Your answer
Emergency Contact
Same as above
Different, contact below...
Name
Your answer
Phone Number
Your answer
Email Address
Your answer
Home Address (Street, City, State, Zip Code)
Your answer
Agreement *
Required
Additional Notes/Comments/Concerns:
Your answer
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