Parent Information
Please read all questions thoroughly and answer them as accurately as possible.
Parent/Guardian FULL Name *
Mrs. Jane Doe
Your answer
Primary Phone Number *
(000) 000-0000
Your answer
Primary Email *
Your answer
2nd Parent/Guardian FULL Name *
Mr. John Doe
Your answer
Secondary Phone Number *
(000) 000-0000
Your answer
Secondary Email *
Your answer
Emergency Contact Name *
Must be a SEPARATE person from the parents/guardians listed above
Your answer
Emergency Contact Phone Number *
(000) 000-0000
Your answer
Please list the FULL names of any other adults you approve to pick-up your child(ren) from our classes *
Adults must confirm their identity via government issued I.D. upon pick-up
Your answer
Is your family currently enrolled in our after school Youth Mentorship Program? *
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