Registration Form

Registration Form

Child’s First Name

Child’s Last Name

Child’s Date of Birth

Parent/Guardian Information

Parent/Guardian #1 Name

Parent/Guardian #2 Name

Relationship to Child

Relationship to Child

Home Street Address

Home Street Address

Home City, State, Zip

Home City, State, Zip

Home Phone

Cell Phone

Home Phone

Cell Phone

Email Address

Email Address

Enrollment Type (Check Type)

Full-‐Time

Part-‐Time

Parent/Guardian Signature

Date Signed:

Main Phone: 267-‐728-‐4684
1209 Vine Street, 3rd Floor, Philadelphia, PA 19107

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