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Bethune Family Night On-Site Childcare
Bethune Family Night On-Site Childcare
November 17, 2022
Complete this form to register for on-site childcare during the Bethune Family Night performance of
Dr. Seuss's How the Grinch Stole Christmas
.
Childcare is offered for children ages 2-4. Provided care hours are 6:30pm through the end of the performance.
Student Information
How many kids will you be bringing?
*
1
2
Student Name 1
*
First
Last
Student 1 Date of Birth
*
MM slash DD slash YYYY
Students must be at least 2 years old
Student Name 2
*
First
Last
Student 2 Date of Birth
*
MM slash DD slash YYYY
Students must be at least 2 years old
Parent/Guardian Information
Parent/Guardian Name
*
First
Last
Email
*
Phone
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Add a 2nd Parent/Guardian?
Yes
If yes, an account will be verified/created
2nd Parent/Guardian Information
Parent/Guardian Name
*
First
Last
Email
*
Phone
*
Same address as Parent/Guardian #1
*
Yes
No
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Alternate Contact
(If we are unable to reach a contact listed above)
Alternate Emergency Contact #1
*
First
Last
Relationship to Student
*
Alternate Emergency Contact #1 Phone
*
Medical Information
Does the student have special considerations, learning needs, allergies, or medications that we should be aware of?
*
Yes
No
(please include any food allergies and/or bee stings)
Please explain:
*
Hidden
Demographic Information
Hidden
Which of the following best describes your student?
*
African American
Alaskan Native
Asian
Black
Hispanic
Latine
Multiracial or Biracial
Native American
Native Hawaiian
Pacific Islander
White
Prefer not to say
Other
Hidden
Tell us more!
*
Hidden
If additional information regarding ethnicity feels relevant for your student, feel free to share below. (Ex. Hispanic, Egyptian, Dominican, Somali, Pakistani, etc.)
Hidden
Acknowledge and Agree to Registration Terms
Read & review
CTC Education & COVID-19 Policies
Hidden
I understand and accept the Medical Policy
Yes
Hidden
I have read and accept CTC's Education Policies
Yes
Hidden
I have read and accept CTC's Education Policies.
*
Yes
Comments
This field is for validation purposes and should be left unchanged.
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