Southern Children's Network, Inc.

Registration Form

General Information
First Name :
Last Name :

Address :
City :
Zip :
County :
Phone No. :
E-Mail :

School Information
School Name :
Grade Level :
Is the student an ESOL * student :	Yes No
* English as a second language
Gender:	Male Female
Have you registered in any of our programs before?	Yes No
Ethnicity
* If Other, please specify :
Is the student a special needs student? *	Yes No
* If yes, please specify :

Parent/Guardian Information
Parent(s) :
Phone No. :
Emergency Contact :
Phone No. :

Program Registering
Please specify which programs you're registering :	Mentor After School Program Tennis Program Tutoring Administration Mentee *
* If you checked mentoring, do you have at least 1 parent/guardian or care giver incarcerated?	Yes No

Bulletin Board

Tue 07th of February 2012

1. Mentor Training ***

Third Monday of Each month:

7:00 PM - 8:30 PM

May call or email for a one on one

training.

Contact Jinaki if you are attending:
770-716-1690 or
wilson@southernchildren.org

***'Please note that the event time may
change with short notice due to
unforeseen circumstances. Please
confirm date and time.