Boosters Student Registration Form
Please fill out the following:
Email address *
Student #1
Name *
School *
Age *
Grade *
Birthday *
MM
/
DD
/
YYYY
Student #2
Name
School
Age
Grade
Birthday
MM
/
DD
/
YYYY
Student #3
Name
School
Age
Grade
Birthday
MM
/
DD
/
YYYY
Contact Information
Parent/ Guardian Name #1 *
Cell phone number *
Work number *
Email Address *
Relationship to child *
Parent/ Guardian Name #2 *
Cell phone number *
Work number *
Email Address *
Relationship to child *
Household Information
Address *
City *
State *
Zip Code *
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
Age
Relation to Child
Name
Age
Relation to Child
Name
Age
Relation to Child
What is the primary language spoken at home? *
Parent English Speaking skill: *
Chuch/ Mosque/ Temple/ Synagogue (if any) your family attends:
Authorized Pick Up
Please list the people that are permitted to pick up your child or walk your child home.
Name #1 *
Phone *
Relationship *
Name #2 *
Phone *
Relationship *
Name #3
Phone
Relationship
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 *
Phone *
Relationship *
Name #2 *
Phone *
Relationship *
Name #3 *
Phone *
Relationship *
Please list any medications, physical limitations, asthma, allergies (food, pollen), or other medical condition related to child:
Student #1
Student #2
Student #3
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