Open Minds Program Registration -- Fall 2019
Student Name *
Your answer
Parent/Guardian Name *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Student's Birthday *
MM
/
DD
/
YYYY
Student's Pronouns *
Emergency Contact Name(s) and Phone(s) *
Your answer
Who has permission to sign the child out after classes? *
Your answer
Medical, Allergy or Other Info
Your answer
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