Program Registration

Enroll in our community programs

Applicant Information

First Name*

Last Name*

Date of Birth*

Gender

Address*

City*

State*

ZIP Code*

Phone Number*

Email Address*

Parent/Guardian Information

Required for applicants under 18 years old

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to Applicant

Parent/Guardian Phone

Parent/Guardian Email

Program Selection

Program Applying For*

Preferred Start Date*

Special Interests or Goals

Emergency Contact Information

Emergency Contact Name*

Relationship*

Primary Phone*

Secondary Phone

Emergency Contact Address

Medical Information

Medical Conditions

Allergies

Current Medications

Special Dietary Needs

Primary Care Physician

Doctor's Phone Number

Insurance Provider

Insurance Policy Number

Special Needs & Accommodations

Physical Accommodations Needed

Learning or Developmental Needs

Communication Needs

Behavioral Considerations

Required Documents

Photo ID*

Upload a copy of government-issued photo ID

Medical Forms

Upload any relevant medical forms or doctor's notes

Insurance Documentation

Upload insurance card or policy information

Additional Documents

Upload any other relevant documents

Agreement and Signature

I certify that all information provided is accurate and complete*

I certify that all information provided is accurate and complete

I authorize emergency medical treatment if needed*

I authorize emergency medical treatment if needed

I give permission for photos/videos for program documentation

I have read and agree to the Rules & Regulations*

I have read and agree to the Rules & Regulations

Signature (Type Full Name)*

Date*

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