Email: contact@clubhousestars.com Phone: 914-674-1940
Child's Information
Child's name: (required)
Child's Date of Birth: (required)
Address: (required)
City: (required)
Home Phone #: (required)
Current Grade in School: (required)
Parent(s)/Guardian(s)
Parent Name: (required)
Parent Name:
Parent Email: (required)
Parent Email:
Parent Cell: (required)
Parent Cell:
Parent Work:
Name(s) of adult(s) who will be picking your child up
Name: (required)
Name:
Cell: (required)
Cell:
Program Information
Name of Program you are enrolling your child in: (required)
Day of Week of Program: (required)
Time of Day: (required)
Which program are you enrolling your child in?
Social Stars Social Skills Playgroup Clubhouse Girls Intensive Summer Program
Other Information
What does your child enjoy doing?
Why are you enrolling your child?
What do you expect your child to gain from this program?
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