Peoria Friendship House Online Registration

Registration

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Welcome to Peoria Friendship House! Please complete the following registration form.

* denotes required fields

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 Provider*

Annual household income?*

Number of people in household*

Do you live in public housing?*

Are you a single parent?*

Contact #1

Contact #1 First Name*

Last Name *

Relation to student*

How Can We Contact You?

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

Relation to student

How can we contact you?

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student's School*

Grade Level*

Are you able to provide transportation for your child to our building if our transportation is full?*

Disabilities or Activity Restrictions? (i.e Asthma, Epilepsy, etc) (Type N/A if NONE)*

Is there any info that you can provide to assist when working w/your child? (Type N/A if NONE)*

Does you child have any allergies? If so, please list. (Type N/A if NONE)*

Is your child on any medications? If so please list. (Type N/A if NONE)*

Ethnicity?*

Hispanic/Latino? (Y/N)*

Please click on the Search button below, then choose the class according to your student(s) grade level.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student's School*

Grade Level*

Are you able to provide transportation for your child to our building if our transportation is full?*

Disabilities or Activity Restrictions? (i.e Asthma, Epilepsy, etc) (Type N/A if NONE)*

Is there any info that you can provide to assist when working w/your child? (Type N/A if NONE)*

Does you child have any allergies? If so, please list. (Type N/A if NONE)*

Is your child on any medications? If so please list. (Type N/A if NONE)*

Ethnicity?*

Hispanic/Latino? (Y/N)*

Please click on the Search button below, then choose the class according to your student(s) grade level.

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student's School*

Grade Level*

Are you able to provide transportation for your child to our building if our transportation is full?*

Disabilities or Activity Restrictions? (i.e Asthma, Epilepsy, etc) (Type N/A if NONE)*

Is there any info that you can provide to assist when working w/your child? (Type N/A if NONE)*

Does you child have any allergies? If so, please list. (Type N/A if NONE)*

Is your child on any medications? If so please list. (Type N/A if NONE)*

Ethnicity?*

Hispanic/Latino? (Y/N)*

Please click on the Search button below, then choose the class according to your student(s) grade level.

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student's School*

Grade Level*

Are you able to provide transportation for your child to our building if our transportation is full?*

Disabilities or Activity Restrictions? (i.e Asthma, Epilepsy, etc) (Type N/A if NONE)*

Is there any info that you can provide to assist when working w/your child? (Type N/A if NONE)*

Does you child have any allergies? If so, please list. (Type N/A if NONE)*

Is your child on any medications? If so please list. (Type N/A if NONE)*

Ethnicity?*

Hispanic/Latino? (Y/N)*

Please click on the Search button below, then choose the class according to your student(s) grade level.

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student's School*

Grade Level*

Are you able to provide transportation for your child to our building if our transportation is full?*

Disabilities or Activity Restrictions? (i.e Asthma, Epilepsy, etc) (Type N/A if NONE)*

Is there any info that you can provide to assist when working w/your child? (Type N/A if NONE)*

Does you child have any allergies? If so, please list. (Type N/A if NONE)*

Is your child on any medications? If so please list. (Type N/A if NONE)*

Ethnicity?*

Hispanic/Latino? (Y/N)*

Please click on the Search button below, then choose the class according to your student(s) grade level.

Enroll in Classes

Select Class *

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Registration

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?

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

(Show-Hide Details)