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)
Name of Program: (required)
Day of Week: (required)
Time of Day: (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:
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?
Which program are you enrolling your child in?
Social Stars Social Skills Playgroup Clubhouse Girls Intensive Summer Program
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