Chegwin School Year Program Registration

Parent/Guardian #1
First and Last Name*
First Last
Home Address*
Street Address Address Line 2 City State ZIP Code
Email*
Cell Phone*
Would you like to receive text message communication to this phone number?*
- Yes
- No
Employer*
Work Phone
Are you active in the Armed Forces?*
- Yes
- No
Parent/Guardian #2
First and Last Name
First Last
Home Address
Same as Parent/Guardian #1

Street Address Address Line 2 City State ZIP Code
Email
Cell Phone
Would you like to receive text message communication to this phone number?
- Yes
- No
Employer
Work Phone
Are you active in the Armed Forces?
- Yes
- No

Child #1 Information
First and Last Name*
First Last
Child's Birth Date*
Month
Day
Year
Child's Gender*
Child's Ethnicity*
Child Lives With*
Child's School Attending*
2024-25 Grade*
Please List any Medical Conditions your Child May Have
Please list any Medications Your Child Takes
Does your child qualify for free or reduced lunch? (Optional)
- Yes
- No
Do you give your child permissions to leave on their own?*
- Yes, anytime
- Yes, after ________________
- No
After what time is your child allowed to leave?*

: Hours

Minutes

AM/PM
Child #1 Media permission

Parent/Guardian #1

First Name	Last Name