eBridge 2019 Summer Program Registration

Email address *
Your Child's Name *
Your answer
Your Child's Preferred Name *
Your answer
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's Gender *
Home Address *
Your answer
Mother or Guardian's Name *
Your answer
Mother or Guardian's Cell Phone Number *
Your answer
Mother or Guardian's Home or Work Number *
Your answer
Mother or Guardian's email
Your answer
Father or Guardian's Name *
Your answer
Father or Guardian's Cell Phone *
Your answer
Father or Guardian's Home or Work Number *
Your answer
Father or Guardian's email
Your answer
Please list the names and telephone numbers of any additional emergency contacts that you are authorizing as a pick up person.
Your answer
Your child's schedule *
Half Days
Full Days
Not Attending
Session 1 (6/10-6/14)
Session 2 (6/17-6/21)
Session 3 (6/24-6/28)
Session 4 (7/1-7/5)
Session 5 (7/8-7/12)
Session 6 (7/15-7/19)
Session 7 (7/22-7/26)
Session 8 (7/29-8/2)
Session 9 (8/5-8/9)
Select consecutive days to attend (3 days minimum): *
Required
Tuition and fees
I hereby release eBridge Montessori School, its employees and representatives from all liability for injury during the program activities. It is further understood that eBridge Montessori School is not responsible for the loss of personal property. *
Required
I agree to the above terms and conditions. Please type your name as an electronic signature.
Your answer
A copy of your responses will be emailed to the address you provided.
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