Please Select the School you are interested in: *

Cicely L. Tyson Elementary School

Langston Hughes School

START DATE *

BEGIN ON OR AFTER JUNE 24, 2024

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Child's Name *

First Name

Last Name

Child's Date of Birth *

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DD

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Child's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Name

First Name

Last Name

Mother Employers Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother Cell Phone Number

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Father's Name

First Name

Last Name

Father Employers Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father Cell Phone Number

(###)

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E1 Name *

First Name

Last Name

E1 Phone *

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E2 Name

First Name

Last Name

E2 Phone

(###)

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Name *

First Name

Last Name

Method of Payment *

Confirmed Programs for Parents

Pending Programs for Parents

Out-Of-Pocket $150 per week

*

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