Registration (K-12) Afterschool Program

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Name of Program Location

(Parents/Guardian) First name

(Parents/Guardian/) Last name

(Parent/Guardian) Address

(Parents/Guardian/) Email

(Parents/Guardian) Phone

Does Your Child Require Any Special Accommodation?

Race *

American Indian/Alaska Native

Asian

Hispanic

Multi-Racial

Black

White

Arabic

Other

Language Spoken In The Home *

English

Spanish

Arabic

French

Chinese

Other

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