Parent Led Academic Network Team, Inc.
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Please complete the following registration form for each student for the 2017 - 2018 school year.
Registration Form
*
Indicates required field
Participant Name
*
First
Last
Birthdate
*
Age
*
Student Email (If Applicable)
*
Parent 1 Name
*
First
Last
Primary Parent contact
Parent 1 Cell Phone
*
Parent 1 Email
*
Parent 2 Name
*
First
Last
Additional parent contact
Parent 2 Cell Phone
*
Parent 2 Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Home Phone Number
*
Individuals Authorized to Pick-up Student
Authorized Individual 1 Name
*
First
Last
Relationship 1 to Participant
*
Authorized Individual 2 Name
*
First
Last
Relationship 2 to Participant
*
Authorized Individual 3 Name
*
First
Last
Relationship 3 to Participant
*
Emergency Contact 1
*
First
Last
Emergency Contact Phone
*
Emergency Contact 2
*
First
Last
Emergency Contact 2 Phone
*
Medical conditions
*
Does the participant have any medical or other conditions that may be aggravated by participating in class (i.e. asthma, allergies)? Please explain.
Challenges
*
Does participant have any conditions that may make participating in this class difficult for him/her?
Referred by:
*
First
Last
For those registering for Say It With Class or Always Be Ready, indicate who referred you and they will receive $10 off their registration.
Submit
Home
About
Network Map
Statement of Faith
For Teachers
>
Terms of Service
Forms
Teacher Tutorials
Teacher Checklist
For Parents
>
SEED Scholarship Fund
Testimonial Form
Parent Testimonials
Parent Tutorials
FAQ for Parents
Photo Gallery
Classes
Register
Resource Directory
Contact
Support
Annual Report
S.T.U.F.F
more S.T.U.F.F