Elementary Wednesday Night Registration
Child's First Name
Your answer
Child's Last Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Grade (entering in Fall 2017)
Street Address
Your answer
City/State
Your answer
Zip Code
Your answer
Parent/Guardian Contact Info:
First Name
Your answer
Last Name
Your answer
Street Address
Your answer
City/State
Your answer
Zip Code
Your answer
Email Address
Your answer
Primary Phone Number
Your answer
Secondary Phone Number
Your answer
Emergency Contact Info:
Name
Your answer
Phone Number
Your answer
Miscellaneous Information:
For K-3 Grade: please list a name of a friend. (optional)
Your answer
Allergies, medical conditions or anything else you would like us to be aware of:
Your answer
Required
Required
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