Do you agree with the Membership Statement Listed Above:*

Yes

No

Email*

First Name

Last Name

Phone Number

Street address

City

Mobile phone number

Student First and Last Name

Date of birth

Gender

School

Emergency Contact Name

Student Mobile Number

List any Allergies (Food or Any Other)

Student Current Grade Level*

6th Grade

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

Health Needs & Special Needs

No Health Conditions / Needs

Does this applicant have a 504 plan?

Yes

No

Communicable Diseases (Such as i.e. HIV, Hepatitis, Lice, etc.)

Yes

No

Diet or Activity Restrictions

Submit