Black Diamond Kids Center Online Registration

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Partnering with parents to empower kids to be: Confident go-getters, Courageous adventurers, Compassionate leaders, Unstoppable champions

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Referral Information

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Referral Name

Family Information

Family Last Name*

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Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

Coupon Code

Contact #1

Contact #1 First Name*

Last Name *

Type*

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Home Phone

Work #

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Confirm Email*

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Contact #2

Contact #2 First Name*

Last Name*

Type

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Home Phone

Work #

Cell #

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Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

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Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

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Student #4 (Show-Hide Details)

Student's First Name*

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Student Gender*

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Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

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Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

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Questions or Concerns

Comments

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

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Student #2 (Show-Hide Details)

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Student #3 (Show-Hide Details)

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Student #4 (Show-Hide Details)

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Required Policies

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Questions or Concerns

Payment Information

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

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Student #3 (Show-Hide Details)

Additional Info

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Student #4 (Show-Hide Details)

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Student #5 (Show-Hide Details)

Additional Info

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I Agree to All of the Above

Questions or Concerns

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