Parker Core Knowledge Online Registration

Registration

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Welcome to Core Care Club registration! Please provide the following information to enroll for the 2020-2021 school year.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info<br/>(Not Contact #1 or #2)*

Alternate Pick Up Person #1*

Alternate #1's Phone Number:*

Alternate Pick Up Person #2*

Alternate #2's Phone Number:*

Military ID # (if applicable):

Contact #1

Parent/Guardian First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Parent/Guardian First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Grade Level*

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Skill Notes

Agree to Photo Release?*

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Grade Level*

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Skill Notes

Agree to Photo Release?*

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Grade Level*

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Skill Notes

Agree to Photo Release?*

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Grade Level*

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Skill Notes

Agree to Photo Release?*

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Grade Level*

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Skill Notes

Agree to Photo Release?*

Add Another Student

Required Policies and Agreements

(Show-Hide Details)

Assumption of Risk

I've read the above and agree.

Payment Policies

I've read the above and agree.

Medical Aknowledgment

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule

Please fill out CREDIT CARD Payment Method

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

Required Policies and Agreements (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Account Information

Credit Card

eCheck/Bank Draft

Required Policies and Agreements

(Show-Hide Details)