Summer Enrichment

Your Youth's Information

Completing this form secures your child a spot into our program. Registration fees are due within 7 days to secure your child's slot in the program.

Youth's First Name:
Please type your full name.

Youth's Last Name:
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Youth's Gender:
Please specify your position in the company

Youth's Birth Date:
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Youth's Age:
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Youth's T-Shirt Size:
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Please List Any Youth's Allergies:
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Please List Any Youth's Medications:
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Do you give us permission to administer medication?
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Who Will Administer Medication?
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Choose the Summer Enrichment week that your youth wants to participate in:
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What REDZONE Program Will Attendee Participate In?
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Are you/child currently enrolled in The REDZONE?
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If not, do you or your child need an assessment?
Please specify your position in the company


Parent/Guardian Contact Information

(1) Parent/Guardian First Name:
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(1) Parent/Guardian Last Name:
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(1) Parent/Guardian Home Phone:
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(1) Parent/Guardian Cell Phone:
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(1) Parent/Guardian Email:
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(1) Parent/Guardian Birth Date:
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(1) Parent/Guardian Occupation:
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(1) Parent/Guardian Address:
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(1) Parent/Guardian City:
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(1) Parent/Guardian State:
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(1) Parent/Guardian Postal / Zip Code:
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(1) Parent/Guardian Employer:
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(1) Parent/Guardian Employer Address:
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(1) Parent/Guardian Employer Phone:
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Emergency Contact Information

Name of Emergency Contact:
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Relationship to Participating Youth:
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Emergency Home Phone:
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Emergency Work Phone:
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Signature and Submit

I acknowledge with the submission of this form that I am agreeing to pay a $20 NON REFUNDABLE registration fee for my child to be enrolled in the Champions Summer Enrichment Program. I understand that my child's spot will not be secured until this fee is paid.

Signature:
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