Enrollment Form

*Please contact Steamboat Reading before completing any enrollment forms.

Student Name

First Name

Last Name

Date of Birth

YYYY

School

Current Grade

Parent Information

Parent #1 Name

First Name

Last Name

Parent #2 Name

First Name

Last Name

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best Contact Phone

(###)

###

####

Secondary Phone

(###)

###

####

Email #1

Email #2

Preferred Contact Method

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Names of people authorized to pick up child

The following people are NOT authorized to pick up child