Grassroots Summer Registration 2020
One form per child
Email address *
Student Information
Child's Name *
Today's Date *
MM
/
DD
/
YYYY
Gender *
Name of Mother *
Name of Father *
Who does child resides with? *
Full Address *
Parent's Phone Number *
Childs Cell Number
Parent's email *
Child's School *
Child's Grade *
Child's Date of Birth *
MM
/
DD
/
YYYY
Ethnicity *
Check all that apply
Required
Free/Reduced Lunch *
Allergies or Special Medical Needs *
Does your child have an Individualized Education Plan, IEP?
If Yes, Please list what IEP.
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