Parent/Guardian First Name*
Parent/Guardian Last Name*
Mailing Street*
Mailing City*
Mailing State*
Zip Code*
Phone
Email*
Name on 2nd membership card (2nd adult in household)
How did you hear about the program?
4th Grader's Full Name*
4th Grader's Birth Date (mm/dd/yyyy)*
4th Grader's School*
4th Grader's Teacher (if still unknown, enter child's 3rd grade teacher)*