CARES ON LINE REGISTRATION FORM

- ADMISSIONS

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- CHILD #1
  
  First, Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Male/Female REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter valid data.
- CHILD #2
  
  First, Last Name Please enter valid data.
  
  Date of Birth Please enter valid data.
  
  Male/Female Please enter valid data.
  
  Grade Please enter valid data.
- CHILD #3
  
  First, Last Name Please enter valid data.
  
  Date of Birth Please enter valid data.
  
  Male/Female Please enter valid data.
  
  Grade Please enter valid data.
- CONTACT INFORMATION
  
  Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Primary Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- PARENTS AND/OR GUARDIAN
  
  Father's Name Please enter valid data.
  
  Phone Number Please enter a phone number.
  
  Email Please enter an email address.
  
  Mother's Name Please enter valid data.
  
  Phone Number Please enter a phone number.
  
  Email Please enter an email address.
- I understand payments are due weekly and I am responsible for all fees and payments. My child/children will not be admitted to the program unless all accounts are current.
  
  I/We Agree Please select this field.
  
  Date REQUIRED Please fill out this field. Please enter a date.
- Thank you for completing this form. Once you click "submit" you will receive instructions on how to pay your registration fee.
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