Educational Success Registration Form - Children and Family Urban Movement

Thanks for your interest! Please complete the form below to register for Educational Success enrichment program(s). 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

Number of Students You Would Like to Register

Student #1 Name*

First Last

Student #1 Date of Birth*

Student #1 Grade*

Use 0 for kindergarten.

Student #2 Name*

First Last

Student #2 Date of Birth*

Student #2 Grade*

Student #3 Name*

First Last

Student #3 Date of Birth*

Student #3 Grade*

What is your preferred language?*

I would like to sign up for…*

Check all that apply

The Haven After School

Awesome Spring Break Days

Awesome Summer Days

Parent/Guardian Email*

Parent/Guardian Phone*

Parent/Guardian 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?

Phone

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