2019-2020 Registration
Please fill out one form for each child you will be registering.
* Required
Email address
*
Your email
How many children are you registering? (please fill out a form for each child)
*
Your answer
Child's First Name
*
Your answer
Last Name
Your answer
Age
*
Your answer
Child's Address
*
Your answer
School
*
Lenart Regional Gifted
Keller Regional Gifted
Grade
*
Choose
K
1
2
3
4
5
6
7
8
Dietary Restrictions
*
Vegetarian
Vegan
Kosher
Halal
Gluten-free
None
Other:
Food and Medical Allergies
*
please list all foods or medications your child cannot have
Your answer
Physican's Name
*
Your answer
Physican's Phone Number
*
Your answer
List any health conditions
Your answer
list any medications your child uses
Your answer
Father Info:
Name
Your answer
Father's Phone Number
Your answer
Father's email
Your answer
Mother's Name:
Your answer
Mother's Phone:
Your answer
Mother's email:
Your answer
Who should receive the monthly invoices?
*
Mother
Father
Both Parents
Which option best describes your needs.
After Care 4-5 days a week ($250 monthly)
After Care 2-3 days a week ($200 monthly)
1 day a week ($25 each visit)
Who does the child live with?
*
Choose
Mother
Father
Both Parents
Other
List all persons that may pick your child up.
Your answer
List any persons not allowed to be in contact with your child.
Your answer
Media Consent
*
I hereby consent to have my child photographed, videotaped, and audio taped, and/or interviewed by individuals as it relates to The STBU only. I understand that my permission must be given before my child's photo is used.
I certify I have read the Media Consent
Payment
*
I understand that my deposit is non-refundable. You will receive a PayPal invoice within 2 business days.
yes
A copy of your responses will be emailed to the address you provided.
Submit
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