Fran Cohen Youth Center of the Salvation Army Online Registration

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Welcome to The Salvation Army Fran Cohen Youth Center. Please complete the following registration form.

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Referral Information

How did you hear about us?

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info*

Health Insurance Carrier

Do you need financial assist.?*

If yes, annual househd income?*

How many live in household?*

Special class accommodation?*

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

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 # *

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

T-Shirt Size

School*

Grade Level in 2022-23*

Transportation

Disabilities (Leave blank if NONE)

Special Needs *

Allergies *

Medications*

Primary Doctor

Immunizations Notes*

Are your immunizations current*

Can your child swim with us?

Anything we should know?*

Grade Level in 2022-2023*

AFTER-SCHOOL PROGRAM 2022-2023

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

T-Shirt Size

School*

Grade Level in 2022-23*

Transportation

Disabilities (Leave blank if NONE)

Special Needs *

Allergies *

Medications*

Primary Doctor

Immunizations Notes*

Are your immunizations current*

Can your child swim with us?

Anything we should know?*

Grade Level in 2022-2023*

AFTER-SCHOOL PROGRAM 2022-2023

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

T-Shirt Size

School*

Grade Level in 2022-23*

Transportation

Disabilities (Leave blank if NONE)

Special Needs *

Allergies *

Medications*

Primary Doctor

Immunizations Notes*

Are your immunizations current*

Can your child swim with us?

Anything we should know?*

Grade Level in 2022-2023*

AFTER-SCHOOL PROGRAM 2022-2023

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

T-Shirt Size

School*

Grade Level in 2022-23*

Transportation

Disabilities (Leave blank if NONE)

Special Needs *

Allergies *

Medications*

Primary Doctor

Immunizations Notes*

Are your immunizations current*

Can your child swim with us?

Anything we should know?*

Grade Level in 2022-2023*

AFTER-SCHOOL PROGRAM 2022-2023

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

T-Shirt Size

School*

Grade Level in 2022-23*

Transportation

Disabilities (Leave blank if NONE)

Special Needs *

Allergies *

Medications*

Primary Doctor

Immunizations Notes*

Are your immunizations current*

Can your child swim with us?

Anything we should know?*

Grade Level in 2022-2023*

AFTER-SCHOOL PROGRAM 2022-2023

Enroll in Classes

Select Class

Add Another Student

Required Policies

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Questions or Concerns

Comments

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?

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 (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Required Policies

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