 | Registration Form
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Child’s Name:
First Middle Last
Name child goes by: __________
Mother’s Name:
First Last
Father’s Name:
First Last
Child’s Birthdate: Age (as of 9/1) Sex:
Address:
Street City Zip
Home Phone: E-mail: _____
How do you prefer to be contacted (circle one): phone e-mail__________
Mother’s Occupation: Bus. #: Cell #: _____
Father’s Occupation: Bus. #: Cell #: _____
Child lives with (circle one): Mom and Dad Mom Dad Other
Child’s Siblings:
Name & DOB Name & DOB
Name & DOB Name & DOB
How did you find out about us?
Parent’s Signature: Date:
For office use only:
Class Enrolled in: Stars Rockets
Committee Position: _______________________________
Work Party: 1 2 3 Fundraiser: December April
Date enrolled: ________ Registration amt. paid:$_______ Other Fees Paid:$_________
Partial Co-op Surcharge paid $_________ for Sept. - Jan. / Feb. - May
