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Registration
- Looking Towards The Future
Student Information
Child's First Name
Child's Last Name
Grade
Mobile Number
-
Email
Birthday
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
,
Gender
Male
Female
Which Program(s) You Would Like To Register For
Reading Enrichment Program
Mentor Program
Computer Literacy Program
Parent/Guardian Name
1. Name:
Phone #:
-
Email:
2. Name:
Phone #:
-
Email:
Mailing Address
City
State
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
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Ohio
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Commonwealths & Territories
Zip Code
Street Address
City
State
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Commonwealths & Territories
Zip Code
Emergency Contacts
1. Name
Phone #
-
Email
2. Name
Phone #
-
Email
I, the parent/guardian of the above named child hereby give my approval to his/her participation in activities of Lil' Jacob Learning Center programs. I assume all risks and hazards incidental to the conduct of the activities. I hereby waive all claims against the organizers, sponsors, directors or any of the supervisors in case of injury to my child.
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