Registration Form 2021-22

SCHOOL YEAR PROGRAM REGISTRATION

Child’s Name *

Child’s Date of Birth *

Gender *MaleFemale

Grade level in Fall 2021 *

School of attendance in Fall 2021 *

Parent name(s) *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Home *

Phone *

Email Address *

Emergency contacts *

Allergies/medical conditions? *

Who can we thank for referring you to Whiz Kids?

Class and day/time preferences (from class schedule)

To help ensure enrollment in a class, it is very important that you indicate your 1^st, 2^nd, and 3^rd choices.