Registration

Looking Towards The Future

Student Information

Leave this empty:

Child's First Name

Child's Last Name

Grade Level

Mobile Number

Email Address

Date of Birth

Month

Day

Year

Gender

Male
Female

Which Program(s) You Would Like To Register For:

Reading Enrichment Program
Mentor Program
Computer Literacy Program

Parent Guardian

Parent/Guardian Name 1

Phone Number

Email Address

Parent/Guardian Name 2

Phone Number

Email Address

Mailing Address

City

State

Zip Code

Street Address

City

State

Zip Code

Emergency Contacts

First Contact Name

Home Number

Email Address

Second Contact Name

Home Number

Email Address

Agreement

I, the parent/guardian of the above named child hereby give my approval to his/her participation in activities of Lil' Jacob Learning Center programs. I assume all risks and hazards incidental to the conduct of the activities. I hereby waive all claims against the organizers, sponsors, directors or any of the supervisors in case of injury to my child.

Date 10/13/2024