Wednesday Night Educational Series Registration Form

First Name

Last Name

Address

City/Town

State

ZIP

Phone #

Series you would like to attend

Why would you like to participate in this series?

Student's Signature

Class series fee is $20 to be paid until a week before class begins

Emergency Contact Information:

Student's Name

Parent/Guardian Name

Parent/Guardian Email

Emergency Contact Individuals:

1. Name

Phone #

Relation to student

2. Name

Phone #

Relation to student

3. Name

Phone #

Relation to student

Other Information:

Please list any of the student’s allergies or any other information it would be helpful to know in case of an emergency

Parent/Guardian Signature

Date

Signature of Participant if over 18, or guardian

Upcoming Events

Virtual Tweens social
October 30, 2020, 3:30 pm - October 30, 2020, 5:30 pm
Virtual STRIVE Night social
October 30, 2020, 6:00 pm - October 30, 2020, 9:00 pm
Virtual Wednesday Night Educational Series: Self Care
November 4, 2020, 6:00 pm - November 4, 2020, 8:00 pm
Virtual Tweens social
November 6, 2020, 3:30 pm - November 6, 2020, 5:30 pm
Virtual STRIVE Night social
November 6, 2020, 6:00 pm - November 6, 2020, 9:00 pm