Defying the Impossible Registration

Part A: STUDENT INFORMATION


City
State/Province
Zip/Postal

Country





Part B: PARENT INFORMATION
The information must be provided. Please provide a minimum of TWO emergency contacts. Only adults indicated on this form will be allowed to pick up your child from the program. Proof of identification will be requested by staff.

City
State/Province
Zip/Postal
Country

City
State/Province
Zip/Postal
Country

City
State/Province
Zip/Postal
Country

Part C: MEDICAL INFORMATION
Part D: WAIVERS, DISCLAIMERS & CONSENT