Enrollment

Green Kids Club Application

Students Name

Age

DOB

Address

Address Line 2

City

Zip

County

Parent/Guardian Name

Phone Number (H)

Cell Number

Contact Name & Number in case of an emergency

School Attended:

Grade:

What are your interest or hobbies?

Is Student involved in sports?

What sport:

Describe your child's math skill

Good

Fair

Poor

Has the Student enrolled in a mentoring or tutoring program?

Yes

Will the child be available Saturday from 10:00AM to 1:00 PM?

Yes

Parent Signature

Date

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(980) 422-1613

(980) 413-5960

FAX: (704) 626-2687