Welcome to our seamless electronic registration process for enrolling your child(ren) in DEFINE's Afterschool or Weekend Character (K-6) and Leadership (7-12) Clubs. We are so excited to welcome you.
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Parent 1 First Name: *

 
Parent 1 Last Name: *

 
Parent 1 Cell Phone (e.g. 214-123-4567): *

 
Parent 1 Skills:

If you would like to volunteer for DEFINE, please list your strengths and how you can help (e.g. IT, marketing, video creation, in-classroom, field trips, events, etc.)
 
Parent 2 First Name: *

 
Parent 2 Last Name: *

 
Parent 2 Cell Phone (e.g. 214-123-4567): *

 
Parent 2 Skills:

If you would like to volunteer for DEFINE, please list your strengths and how you can help (e.g. IT, marketing, video creation, in-classroom, field trips, events, etc.)
 
Home Street Address: *

 
City: *


 
State (2 letter abbreviation): *

 
Zip Code: *

 
Child Information:

 
Child 1 First Name: *

 
Child 1 Last Name: *

 
Child 1 Gender: *


 
Child 1 Date of Birth (e.g. 01-31-2010): *

 
Child 1 Applying For Group: *


 
Child 1 Applying For Program: *


 
Child 1 allergies, health conditions, medications:

 
Register Another Child? *

     
 
Child Information:

 
Child 2 First Name: *

 
Child 2 Last Name: *

 
Child 2 Gender: *


 
Child 2 Date of Birth (e.g. 01-31-2010): *

 
Child 2 Applying For Group: *


 
Child 2 Applying For Program: *


 
Child 2 allergies, health conditions, medications:

 
Register Another Child? *

     
 
Child Information:

 
Child 3 First Name: *

 
Child 3 Last Name: *

 
Child 3 Gender: *


 
Child 3 Date of Birth (e.g. 01-31-2010): *

 
Child 3 Applying For Group: *


 
Child 3 Applying For Program: *


 
Child 3 allergies, health conditions, medications:

 
Register Another Child? *

     
 
Child Information:

 
Child 4 Last Name: *

 
Child 4 First Name: *

 
Child 4 Gender: *


 
Child 4 Date of Birth (e.g. 01-31-2010): *

 
Child 4 Applying For Group: *


 
Child 4 Applying For Program: *


 
Child 4 allergies, health conditions, medications:

 
My child(ren) may be released to the following people (list full name, relationship to student, phone): *

 
EMERGENCY CONTACTS for my child(ren) (list full name, relationship to student, phone): *

 
Parental Consent: Click all those you GIVE parental consent for: *

DEFINE is not liable or financially responsible for any medical care or transport fees.

 
I verify I am the parent of the child(ren) enrolled and provided the information in this form accurately.

 
How did you hear about DEFINE? *


 
Today's Date: *

 
We are currently running a $25 discount on our one-time $100 registration fee. Based on your selections, your total registration comes to {{var_price}} *

 
Please enter your Credit or Debit Card number: *

 
The CVC number: *

(3 or 4 digit security number on the back of your card)
 
The name on your card: *

 
Your card's expiry month: *


 
Your card's expiry year: *


Thank you for investing in your child's character and tarbiyah. We look forward to working with your family. If you have paid the registration fee through this form, you can automate the monthly tuition here in by the 1st Sunday of September 2017: bit.ly/define_weekend_pay.
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