Programs 4 All Kids Registration Page

Registration Page

All information with a red asterisk ( * ) is required.

Last Name *

First Name *

Nick Name

Birthday mm/dd/yyyy *

Sex

Age Group *

Program *

Address

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Phone *

Other Phone

Email *

Other Email

Contact Phones

Father's Information
Last Name

First Name

Cell Phone

Mother's Information
Last Name

First Name

Cell Phone

Emergency Contact
Last Name

First Name

Phone

Additional Information

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Please send check or money order to confirm individual registrations to:

Programs 4 All Kids
3280 Sunrise Hwy
Suite #279
Wantagh, NY 11793

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