1. Date Registered: *

2. Student Name: *

3. Student Date of Birth: *

4. Parent phone number: *

5. Parent/student cell number: *

6. Address: *

7. Grade Level: *
123456789101112

8. Days Attending (select all that apply) could be virtual too *
MondayTuesdayWednesdayThursdayFridaySaturdaySunday

9. From what to what time will the student come? (EX: 3:00-4:00): *

10. Date Start: *

11. Date End: *

12. Email: *

13.Parent/ Guardian Full Name: *