subject_line
Extended Day Enrichment
Registration and Tuition Commitment Form
General Registration Information
Student Information
Student First Name
*
Student Last Name
*
Student ID #
*
Student Grade (2024-2025)
*
K
1
2
3
4
5
6
School Attending (2024-2025)
*
Clinton
Norwood
Boyle
Terryville
JFK
Student Date of Birth
*
+
Student Home Street Address
*
Town
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Parent/Guardian #1
Full Name
*
Contact Email Address
*
Primary Phone #
*
Secondary Phone #
Tertiary Phone #
Parent/Guardian #2
Full Name
Primary Phone #
Secondary Phone #
Tertiary Phone #
Emergency Contacts
I give permission for my child to be picked up by any of the people listed below (non-parental):
*
clear
Emergency Contact #1 Full Name
*
Relationship to Student
*
Phone Number
*
Emergency Contact #2 Full Name
Relationship to Student
Phone Number
Emergency Contact #3 Full Name
Relationship to Student
Phone Number