• Child's First Name

  Child's Last Name
  

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  Make Required
• Birthday
  

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  Make Required
• 2nd Participant First Name

  2nd Participant Last Name
  2nd Participant Birthday
  Add Another Participant
  
• Street Address
  Address Continued
  City

  State/Province
  Postal Code
  

  ---

  Make Required
• Email Address

  

  ---

  Make Required
• Mobile Phone
  

  ---

  Make Required
• Parent's First Name

  Parent's Last Name
  

  ---

  Make Required
• What school does your child attend?

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  Make Required
  
• What specifically would you like your child to accomplish in our After School Program?
  

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  Make Required
• Does your child have any medical concerns that we should be aware of?
  

  ---

  Make Required
• Please check the benefits most important to you.

  Self-Confidence

  Self Esteem

  Respect

  Improved Behavior

  Physical Fitness

  Weight Control

  Strength & Flexibility

  Coordination

  Focus

  Self-Discipline

  Burn Energy

  Leadership

  Fun!

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  Make Required
  
  Self-Confidence,Self Esteem,Respect,Improved Behavior,Physical Fitness,Weight Control,Strength & Flexibility,Coordination,Focus,Self-Discipline,Burn Energy,Leadership,Fun!

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