Registration
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Welcome to The Rock Mill! Please complete the following registration form.
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Referral Information
How did you hear about us?
Coupon
Exhibition
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Other
Parents Magazine
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Referral
Returning Family
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Referral Name
Family Information
Family Last Name
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Contact #1
Contact #1 First Name
*
Last Name
*
How Can We Contact You?
Home Phone
Work #
Cell #
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Portal Access (your email is your login)
Email
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(Emails are kept confidential)
Confirm Email
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Portal Account Password
Confirm Portal Account Password
Student #1
Student's First Name
*
Last Name
*
Student Gender
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Female
Male
Birth Date
*
Additional Info
T-Shirt Size
Adult Large
Adult Medium
Adult Small
Adult X-Large
Adult XX-Large
Child Large
Child Medium
Child Small
Child X-Small
Special Needs *leave blank if none*
Allergies *leave blank if none*
Student #2
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Additional Info
T-Shirt Size
Adult Large
Adult Medium
Adult Small
Adult X-Large
Adult XX-Large
Child Large
Child Medium
Child Small
Child X-Small
Special Needs *leave blank if none*
Allergies *leave blank if none*
Student #3
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Additional Info
T-Shirt Size
Adult Large
Adult Medium
Adult Small
Adult X-Large
Adult XX-Large
Child Large
Child Medium
Child Small
Child X-Small
Special Needs *leave blank if none*
Allergies *leave blank if none*
Student #4
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Additional Info
T-Shirt Size
Adult Large
Adult Medium
Adult Small
Adult X-Large
Adult XX-Large
Child Large
Child Medium
Child Small
Child X-Small
Special Needs *leave blank if none*
Allergies *leave blank if none*
Student #5
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Additional Info
T-Shirt Size
Adult Large
Adult Medium
Adult Small
Adult X-Large
Adult XX-Large
Child Large
Child Medium
Child Small
Child X-Small
Special Needs *leave blank if none*
Allergies *leave blank if none*
Add Another Student
Required Policies
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I Agree to All of the Above
Enter your Full Name
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October 13, 2024
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(9-digit number)
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