Grace Discovery Center Online Registration

Registration

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Welcome! Thank you for choosing Grace! Please fill out the registration form below and then contact the front office to finalize your registration! (Your card will be charged a $50 registration fee upon submitting this form)

* denotes required fields

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 Info (Not Contact #1 or #2)*

Health Insurance Carrier*

CCS?

Parent Share Of Cost

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell #

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name*

Last Name*

Type*

How can we contact you?

Home Phone

Work #

Cell #

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

Student Email*

T-Shirt Size

School*

Current Grade Level*

Transportation Approval*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Immunization Notes*

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email*

T-Shirt Size

School*

Current Grade Level*

Transportation Approval*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Immunization Notes*

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email*

T-Shirt Size

School*

Current Grade Level*

Transportation Approval*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Immunization Notes*

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email*

T-Shirt Size

School*

Current Grade Level*

Transportation Approval*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Immunization Notes*

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email*

T-Shirt Size

School*

Current Grade Level*

Transportation Approval*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Immunization Notes*

Add Another Student

Required Policies and Agreements

(Show-Hide Details)

Operation Policies

I've read the above and agree.

Monetary Policies

I've read the above and agree.

Assumption of Risk

I've read the above and agree.

Permissions

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name* December 21, 2024

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)

Contact #2

How can we contact you?

Who is your employer?

Student #1

Additional Info

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

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

(Show-Hide Details)