2014 Application

  * Means Information Is Required
* Child's Name
* Child's Address
* Zip Code
* Date of Birth
* Gender
* Grade in Fall 2014
* School
* Scholarship Requested (Income Verification Required)

  PARENT/GUARDIAN INFO
* 1. Name
* Address
Home Phone
Cell Phone
Work Phone
Employment
Email
  PERSONS (AGE 16 OR OLDER) AUTHORIZED FOR PICK UP OTHER THAN PARENT
1. Name
Phone
2. Name
Phone

  EMERGENCY CARE INFORMATION
* Doctor's Name
Phone
* Hospital Preference
Information about your child (List allergies, restrictions, special needs, medication, other):

  FINE ARTS SELECTION
* 1st Choice
* 2nd Choice
* I agree that the program operator may authorize the doctor of their choice to provide emergency care if I nor the family doctor can be contacted. * I agree that the program operator may authorize the doctor of their choice to provide emergency care if I nor the family doctor can be contacted.
* I give permission for use of my child's photo and/or likeness in media related to the Afterschool/Summer Institute. * I give permission for use of my child's photo and/or likeness in media related to the Afterschool/Summer Institute.
* I understand that my child may be dismissed from the Afterschool/Summer Institute as a result of continuous discipline problems. * I understand that my child may be dismissed from the Afterschool/Summer Institute as a result of continuous discipline problems.

* Payment Options

  Billing Address
* Country
* Address
* City
* State
* Zip Code

  Payment Information
Total Price: $0.00
* Credit Card Type
* Name on Credit Card
* Credit Card Number
* Expiration Date
* CCV Code click here for help
 


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