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Program name: *
Program date: *
Program code: *
Program fee: *
Program Application Form
Participant Information:
Name: *
Address: *
Birth date: *
Age at Program: *
Parent: *
Address: *
City: *
State/Zip: *
Home phone: *
E-mail: *
Work phone:
Cell phone:
Prefers to be called: *
City: *
State/Zip: *
Female
Male
Parent:
Address:
City:
State/Zip:
Home phone:
E-mail:
Work phone:
Cell phone:
Please provide the following information about the participant:
Does your child have any known allergies?
Does your child carry an Epipen for any allergies?
Is your child currently under the professional care
for any physical and/or mental health condition(s)?
Has your child been hospitalized within the
past 24 months?
Yes
Yes
Yes
Yes
No
No
No
No
If yes, please explain:
If yes, please explain:
If yes, please explain:
If yes, please explain:
All fields marked * are required
Parent/Guardian Information:

Please note:

If you prefer, you may download a PDF version of this Program Application form here and mail it to us with the
program fee. Checks payable to: Zebra Crossings.

For credit card payments of program fees, please also use the PayPal donate button. Please enter the participant's name and program code in the appropriate fields. Your payment will be marked as program fee.

Upon review of your application we will inform you of registration in the program.
Specific program information, directions, what to bring, and contact information will be included in the confirmation packet.

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