EXHIBIT D: REGISTRATION FORM

Each participant must complete the registration form in order to participate in the program. The following information must be provided by the parent/guardian (provide copies):

• Photo Identification
• Proof of Address (Utility Bill)
• Proof of one of the following:
  • Medical Card
  • Supplemental Nutrition Assistance Program (SNAP)
  • Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

Child First Name:

Please enter the child’s first name.

Child Last Name:

Please enter the child’s lsat name.

Address:

Please enter the address.

City:

Please enter the city.

State:

Please enter the state.

Zip Code:

Please enter the zip code.

Phone:

Please enter the phone number.

Email:

Please enter the email.

Parent/Guardian First Name:

Please enter the parent’s/guardian first name.

Parent/Guardian Last Name:

Please enter the parent’s/guardian last name.

First time attending?

Yes No

Race

Black White Asian American Indian/American Native Native Hawaiian/Other Pacific Islander

Ethnicity

Hispanic Non-Hispanic

Parent/Guardian Signature:

Please Sign it.

Clear

Date:

Please fill out this field.

Photo Identification :

Please provide documents.

Proof of Address:

Please provide documents.

Medical Card/Supplemental Nutrition Assistance Program (SNAP)/Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

Please provide documents.

Submit