Remote Learning Online Registration

Online registration

* Indicates required field

Parent/Guardian Name *

First

Last

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

What day (s) would you like to attend? (mark as many as you would like) *

Tuesday Thursday Friday

Student Name *

First

Last

Phone Number *

Age *

Grade *

School *

Teacher *

Emergency Contacts

Name *

Phone Number *

Name *

Phone Number *

Physician Name *

Phone Number *

Consent for emergency transport *

Yes No

Allergies/Medical *

Parent or guardians who will drop off and pick up student *

Untitled *

By signing below, I agree that my student will follow all instruction of the Carr Center and COVID policies. I also agree that I will notify the Carr Center of any changes to the above information and the student's schedule.

Signature *

Date *

Submit

online registration

Online registration