Registration
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Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Type
*
Charter Teacher
Doctor/Physician
Father
Grandparent
Guardian
Mother
Other
Parent
Step Father
Step Mother
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
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:
Female
Male
Non-binary
Prefer not to say
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
Female
Male
Non-binary
Prefer not to say
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
Female
Male
Non-binary
Prefer not to say
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
Female
Male
Non-binary
Prefer not to say
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
Female
Male
Non-binary
Prefer not to say
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Questions/Options:
Last Name
*
First Name
*
Teen Email Address
*
Phone Number
*
Parent Name
*
Parent Email
*
Parent Phone Number (Home)
Parent Phone Number (Cell)
*
Emergency contact name and phone number.
*
Are you currently homeschooled?
*
Yes
No
If you are not currently homeschooled, who are you a guest of. (If you are the homeschooler type NA)
*
Meal: Chicken?
*
Yes
No
Meal: Vegan/Gluten Free
*
Yes
No
Will you be 18 years of age the day of the event?
*
Yes
No
I give permission for my child to sign themselves out at the end of prom. I understand once my child is signed out the LA Homeschool Prom is no longer responsible for my child. If 18 years click yes.
*
Yes
No
For dinner seating please list what homeschool group you are with and anyone you would like to sit with.
*
Who is your favorite recording artist?
Additional Information:
Other Questions/Comments:
Credit Card Verification:
Card Number:
*
Visa
Mastercard
Name as it appears on card:
*
Nickname:
Card Expiration Month:
*
01
02
03
04
05
06
07
08
09
10
11
12
Exp Year:
*
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
Address Line 1:
Address Line 2:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
VI
Zip:
*
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