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Student Information
Student Name
*
First
Last
Student Date of Birth
*
Date Format: MM slash DD slash YYYY
Parent/Guardian Information
Parent/Guardian Name
*
First
Last
Email
*
Day Phone
*
Evening Phone
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
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Maryland
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Ohio
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South Carolina
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Texas
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Armed Forces Americas
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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
*
Day Phone
*
Evening Phone
Same address as Parent/Guardian #1
*
Yes
No
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
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
*
Alternate Emergency Contact #2
First
Last
Relationship to Student
Alternate Emergency Contact #2 Phone
Alternate Emergency Contact #3
First
Last
Relationship to Student
Alternate Emergency Contact #3 Phone
Are there any individuals who are NOT authorized to pick-up the student?
Yes
If yes, please list names.
Please list names of any individuals not authorized to pick up the student
Medical Information
The student is covered by a medical insurance/assistance plan
*
Yes
No
Medical Insurance/Assistance Provider
Policy Number
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:
*
Acknowledge and Agree to Registration Terms
Read & review
CTC Education & COVID-19 Policies
I understand and accept the Medical Policy
Yes
I have read and accept CTC's Education Policies
Yes
I have read and accept CTC's Education Policies.
*
Yes
I have read and accept CTC's COVID-19 Safety Policies.
*
Yes
Photo Release
*
Yes, I give my permission for photos/videos of my child(ren)'s participation in CTC Education Programs to be used for promotional or grant development needs.
I DO NOT give permission for photos/videos of my child(ren) to be used for promotional or grant development needs.
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