A to Z Registration | Tomaro's C.H.A.N.G.E

A to Z Culture & Wellness Program

'Registration Form'

Child's First name

Child's Last name

Child's Birthday

Month

Day

Year

Parent's First Name

Parent's Last Name

Relationship to Child

Parent/Guardian's Address

City

State

Zip Code

Parent/Guardian's Contact #

Parent/Guardian's Email Address

Child's Gender

Male

Female

Other

If Other, Explain

Child's Grade

Child's Ethnicity

What Are Your Child's Strengths

What Are Your Child's Weaknesses

Tell Us About Any Fears, Anxieties, Or Negative Behaviors We Should Know About

What Would You Like Your Child To Take Away From This Program

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact's #

Emergency Contact's Email Address

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact's #

Emergency Contact's Email Address

Does Your Child Have Medical Issues

Yes

No

If Yes, Explain

If You Answered Yes to Medical Issues & Your Child Needs Medication During Program Hours, Please Explain and Include Instructions

If There is Anything Else We Should Know Please Share

Signature

By signing above, you agree that the information above is true and you agree to enter your child into A to Z Cultural Wellness Program. Your signature serves as consent for Tomaro's CHANGE's Team work with and care for your child during our program hours.

Date

Month

Day

Year

If you are registering more than one child, please contact our office to receive your sibling discount!

Check to Confirm Registration Fee Payment

Registration Fee$75