C.A.R.E. Registration 2017/2018
Fill out the form, a copy will be emailed to you with further instructions. You will need to create a new form for each child/each class.
Email Address *
Your answer
Course Selection (If a class says "Waitlist" you may still select it and you'll be contacted if a spot opens) *
Student First Name *
Your answer
Student Last Name *
Your answer
Date of Birth *
Your answer
Home Phone Number *
Your answer
Mobile Number *
Your answer
Additional Mobile Number
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Mother's Name *
Your answer
Father's Name *
Your answer
Students Physician *
Your answer
Physician's Phone *
Your answer
Primary Medical Insurance Company *
Your answer
Policy Holder's Name *
Your answer
Policy Number *
Your answer
Group Number *
Your answer
In Case of Emergency Call: Name, Number, Relationship *
Your answer
Allergies/Medical Conditions or other events/conditions - Allergies that should be known to instructor and CARE Program regarding your child.
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms