Kandelia Youth Programs Registration
Please note: Most classes will be held online through Zoom or Microsoft Teams. After school programs will be mostly virtual until further notice. You will be contacted with more details after we get your application!

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Student's FIRST name? *
Student's LAST name? *
Email (ex. @gmail, @yahoo) *
Student's address? *
Student's phone number? *
Can we text the this phone number? *
What is the best way to contact you? *
Required
Grade: *
Student's gender? *
Student's date of birth? (ex. 01/31/2005) *
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What school does the student go to? *
Race? *
Native country? *
Language(s) spoken at home: *
PARENT/GUARDIAN CONSENT
Parent/Guardian's Name? *
Parent/Guardian's Phone Number? *
Emergency Contact Name & Phone Number (if different from above)
I support my child's interest in the Extended Day Program and give him/her permission to participate in in-person and online based classes through Kandelia and partner organizations, including regular contact through email/ phone, and the use of web-based programs such as Zoom and Microsoft Teams. *
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Medical Release: As the parent/guardian of this student, I authorize and consent to medical, surgical, hospital care, treatment and procedures to be deemed immediately necessary if advisable by a physician to safeguard my child’s health if I cannot be contacted. *
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Photo Release: I hereby grant SWS, Kandelia, and partner organizations to take pictures/video of and/or publish pictures/video of my child for website and other publications (brochures, calendar display). *
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