Multiple Households?

Adults/Guardians are in separate Households

Children's Household

Parent/Guardian 1Parent/Guardian 2

Are you a first time participant in Student to Student?

Child Information

First Name

Last Name

Cell Phone

Date of Birth

Grade

Adult/Guardian 1

First Name

Last Name

Date of Birth

Cell Phone

Street Address

City

State

Postal Code

Adult/Guardian 2

First Name

Last Name

Date of Birth

Cell Phone

Street Address

City

State

Postal Code

Additional Information

Do you need any accommodations to make this experience meaningful?

Do you or your children have any allergies or health concerns? If so, please list.

I give permission for any photographs taken of my child(ren) be used for promotional purposes:

We consent to the Code of Conduct:

The adult facilitator can contact my child directly with program updates:

Payment Information

Amount Due

.00

Name on Card

Card Number

MM (2 Digit)

YY (2 Digit)

Code

Billing Email

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