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Registration - Families Living Well

Registration - Families Living Well

* Indicates required information
Program * 
Program Location 
Student's Name * 
Birthdate *  (mm/dd/yyyy)
Age * 
Gender (M/F) 
Home Address (Street, City, Zip) * 
Telephone Number * 
E-mail Address 
Preferred Language 
Does the student have an IEP (Individual Education Plan)? * 

Does the student have any special needs or disability? * 

If "Yes", please describe 
Please list any food allergies 
Emergency Contact Name * 
Emergency Contact Phone Number * 
Relation to student * 
Parent or Guardian Name * 
I give permission for my child to participate in program (initials serve as signature) * 
Authentication * 

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Note: Fee for all classes are payable at first class with the exception of Chop Chop Cooking Camp, which must be sent prior to the start of camp to: SMMC/Joann Dorr, 1201 Langhorne-Newtown Road, Langhorne, PA 19047. Checks made out to SMMC.