Boosters Student Registration Form
Please fill out the following:
Email address *
Student #1
Name *
Your answer
School *
Your answer
Age *
Your answer
Grade *
Your answer
Birthday *
MM
/
DD
/
YYYY
Student #2
Name
Your answer
School
Your answer
Age
Your answer
Grade
Your answer
Birthday
MM
/
DD
/
YYYY
Student #3
Name
Your answer
School
Your answer
Age
Your answer
Grade
Your answer
Birthday
MM
/
DD
/
YYYY
Contact Information
Parent/ Guardian Name #1 *
Your answer
Cell phone number *
Your answer
Work number *
Your answer
Email Address *
Your answer
Relationship to child *
Parent/ Guardian Name #2 *
Your answer
Cell phone number *
Your answer
Work number *
Your answer
Email Address *
Your answer
Relationship to child *
Household Information
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Please list any other sibling/cousin or child under the age of 18 that is living within the household and NOT applying for afterschool.
Name
Your answer
Age
Your answer
Relation to Child
Your answer
Name
Your answer
Age
Your answer
Relation to Child
Your answer
Name
Your answer
Age
Your answer
Relation to Child
Your answer
What is the primary language spoken at home? *
Parent English Speaking skill: *
Chuch/ Mosque/ Temple/ Synagogue (if any) your family attends:
Your answer
Authorized Pick Up
Please list the people that are permitted to pick up your child or walk your child home.
Name #1 *
Your answer
Phone *
Your answer
Relationship *
Your answer
Name #2 *
Your answer
Phone *
Your answer
Relationship *
Your answer
Name #3
Your answer
Phone
Your answer
Relationship
Your answer
Emergency Contact
In case of an emergency, the parent(s) will be the first contacted, but in the case that you could not be reached, please list 1 to 3 adults that could be contacted.
Name #1 *
Your answer
Phone *
Your answer
Relationship *
Your answer
Name #2 *
Your answer
Phone *
Your answer
Relationship *
Your answer
Name #3 *
Your answer
Phone *
Your answer
Relationship *
Your answer
Please list any medications, physical limitations, asthma, allergies (food, pollen), or other medical condition related to child:
Student #1
Your answer
Student #2
Your answer
Student #3
Your answer
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