Client Registration

Please fill out the form below to begin the registration process for each client you'd like to register.

Step #1. Parent/Guardian Contact Information

Your First Name *

Your Last Name *

Email *

Phone *

Address *

City *

State *

Postal code *

Best Time to Contact You?

Morning

Afternoon

Evening

Step #2: Client Information

Client Name *

Client Date of Birth *

Client's Background *

Additional Notes

Step #3: SDRC or School Information

SDRC Coordinator Name

Coordinator Unit #

Coordinator Phone

Coordinator Email

Contract Start Date

Contract End Date

Charter School Attended

Grade in School

Step #4: Waiver

Captcha

By submitting my electronic signature, I acknowledge that I have read and understand the required waivers and agree to their stipulations as outlined therein. By providing my phone number, I agree to receive text messages from the business.

Please use your finger, stylus, or mouse/trackpad to sign in the box below.

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