Create Center Arts & Technology Environment, Inc.

First Name *

Last Name *

Middle Initial

Street Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Male or Female? *

MaleFemale

Age (5-17) *

Hours of child care required (school hours are 6:30 am to 5:30 pm) *

Full dayHalf-day morningHalf-day afternoonOther (write below)

Other

Days of the week required *

MondayTuesdayWednesdayThursdayFriday

Parent's/Guardian's name *

Phone number *

Place of work

Email address

First name

Last name

Primary phone number

Secondary phone number

First Name

Last Name

Primary phone number

Secondary phone number

First name

Last name

First name

Last name

Doctor

Doctor's phone number

Dentist

Dentist's phone number

Preferred hospital

Insurance/health coverage

Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.

Registration