Preparing our YOUTH for the CAREERS of the FUTURE!

Student Application

# of Children

1 child 2 children 3 children

First Name *

Last Name *

Phone *

Birthday *

Gender *

Second Child

First Name *

Last Name *

Phone *

Birthday *

Gender *

Third Child

First Name *

Last Name *

Phone *

Birthday *

Gender *

Parent or Guardians Information

First Name *

Last Name *

Email Address *

Address *

City *

Desired Start Date *

Phone 1*

Phone 2 (optional)

Emergency Contacts

First Name *

Last Name *

Email Address *

Phone *

How did you hear about us? *

Relationship to the student *

Medical Information

Does this student have? Allergy *

Yes No

Special Needs

Yes No

Dietary Restrictions

Yes No

Physical Restrictions

Yes No

Notes

Student Application

# of Children

1 child 2 children 3 children

First Name *

Last Name *

Phone *

Birthday *

Gender *

Second Child

First Name *

Last Name *

Phone *

Birthday *

Gender *

Third Child

First Name *

Last Name *

Phone *

Birthday *

Gender *

Parent or Guardians Information

First Name *

Last Name *

Email Address *

Address *

City *

Desired Start Date *

Phone 1*

Phone 2 (optional)

Emergency Contacts

First Name *

Last Name *

Email Address *

Phone *

How did you hear about us? *

Relationship to the student *

Medical Information

Does this student have? Allergy *

Yes No

Special Needs

Yes No

Dietary Restrictions

Yes No

Physical Restrictions

Yes No

Notes

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Riverside STEAM Club

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After-School Program in Riverside

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