WSSD Community Learning Center Program
CLC Registration Form

Each student needs a separate form.
Email address *
Student First Name *
Student Last Name *
Student Date of Birth (MM/DD/YYYY) *
Grade *
Home Address *
City *
Mother Name *
Mother Home Phone *
Mother Cell Phone
Mother Work Phone
Father Name *
Father Cell Phone *
Father Work Phone
Emergency Contact #1 *
Emergency Contact #1 Phone Number *
Emergency Contact #2 *
Emergency Contact #2 Phone Number *
Physical Limitations:
Food Allergies:
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