Date of birth *

Parent/ Guardian Name *

Phone *

Email *

Emergency Contact Name ( Must Be Someone That Is Not A Parent or Guardian) *

Emergency Contact Phone Number *

What is the students current grade? *

What school does your child attend? *

Is this your first time registering? *

Does your child have IEP? *

Does your child have any behavioral issues? *

Does your child have any attention issues? *

Does your child recieve occupational services? *

For funding purposes for our program, please answer the following questions: How many people live in your household? *

For funding purposes for our program, please answer the following questions: How many people under 18 live in your household? *

Do you give permission for this child to be photographed of in videography for Soaring As Eagles promotional of social media use? *

Yes

No

I, as the parent/guardian, authorize Soaring As Eagles to provide medical attention for my child in the event of an emergency: *

Yes

Parent/ Guardian Signature *