Educational Success Registration Form - Children and Family Urban Movement

Thanks for your interest! Please complete the form below to register for our after-school enrichment program. Once we receive your application, we’ll be in touch to discuss your eligibility and next steps.

"*" indicates required fields

Parent/Guardian Name*

First Last

Student's Name*

First Last

Grade

Age

I would like to sign up for...

Parent/Guardian Email

Parent'/Guardian Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you employed?

Yes

What are you looking to get out of the program(s)?

Do you have any special needs or requests?

This field is for validation purposes and should be left unchanged.