Registration

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Superheroes, assemble! Jump Start Plus needs your help to defeat the evil villains lurking nearby. Train your superhero skills, activate your powers, and get ready to save the day in this action-packed adventure!

Event:

Start Date/Time:

End Date/Time:

Fee per Student:

Room:

* - denotes required fields

Family Information

	First Name:*	Last Name: *
	Type*
	Home Phone:*	Cell #: Work #:
	Email:*	(Emails are kept confidential)

	Address: *
	City: *	State: * Zip: *
	Emergency Contact Info*

Students entered below will be added to your family's account

Add New Student #1:

(Show-Hide Details)

	Student's First Name: *	Last Name: *
	Student Gender: *	Birth Date: * (format=mm/dd/yyyy)
	School:	Grade Level:
	List any known allergies/allergic reactions::
	List any Medications::
	Primary Doctor's Name & Phone # & Date of Last Exam:*
	List any previous surgeries:
	List any previous broken bones:
	List any other health concerns:

Additional Information: