APEC Family Foundation Fund, Inc Online Registration

Registration

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Welcome to the APEC Family!

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Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Name/ Address/ Phone Number*

Health Insurance Carrier

Employer*

Employer Phone*

Employer Address*

Scheduled Student Start Date: *

GACAPS Recipient? Yes or No*

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # * Receive Text Message Notifications

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Who is your employer?

Employer*

Employer Phone*

Employer Notes

Contact #2

Contact #2 First Name*

Last Name*

Type*

How can we contact you?

Home Phone

Work #

Cell # * Receive Text Message Notifications

Email* (Emails are kept confidential)

Confirm Email*

Who is your employer?

Employer*

Employer Phone*

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor Name*

Immunization Notes

Authorized Pick Up Name:*

Authorized Pick Up Address:*

Relationship to Child:*

Relationship to Parent:*

Primary Doctor Phone Number*

Please indicate the class you are enrolling in.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor Name*

Immunization Notes

Authorized Pick Up Name:*

Authorized Pick Up Address:*

Relationship to Child:*

Relationship to Parent:*

Primary Doctor Phone Number*

Please indicate the class you are enrolling in.

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor Name*

Immunization Notes

Authorized Pick Up Name:*

Authorized Pick Up Address:*

Relationship to Child:*

Relationship to Parent:*

Primary Doctor Phone Number*

Please indicate the class you are enrolling in.

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor Name*

Immunization Notes

Authorized Pick Up Name:*

Authorized Pick Up Address:*

Relationship to Child:*

Relationship to Parent:*

Primary Doctor Phone Number*

Please indicate the class you are enrolling in.

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor Name*

Immunization Notes

Authorized Pick Up Name:*

Authorized Pick Up Address:*

Relationship to Child:*

Relationship to Parent:*

Primary Doctor Phone Number*

Please indicate the class you are enrolling in.

Enroll in Classes

Select Class *

Add Another Student

Required Policies and Agreements

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Questions or Concerns

Comments

Payment Information

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*

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)

Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies and Agreements (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies and Agreements

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