Club eXcel Online Registration

	Please provide the followiing information.

	Student's Full Name*

	Date of Birth*
	mm/dd/yyyy

	Start date?*
	mm/dd/yyyy

	Gender:*
	Gender:* Male  Female

	Address Information:*
	Street Address   City   State   Zip Code

	School Information for 2018-2019 school year:*
	Campus   Teacher   Grade

	Mother or Legal Guardian 1 Information:*
	Name   Birthday   Cell Phone Number   Home Address   Home Phone Number   Employer   Employer Phone Number   Email   Employer Address   Work Schedule

	Father or Legal Guardian 2 Information:
	Parent/Guardian Name:   Home Address   Birthday   Cell Phone Number   Home Address   Home Phone Number   Employer   Employer Phone Number   Email   Employer Address   Work Schedule

	List anyone, including mother and father, who may pick up your child from Club eXcel.
	#1 Name   Relationship   Driver's License Number   Phone Number   #2 Name   Relationship   Driver's License Number   Phone Number   #3 Name   Relationship   Driver's License Number   Phone Number   #4 Name   Relationship   Driver's License Number   Phone Number

	List at least two local people to call, other than parents or persons listed above, in case of emergency or other reasons and if parents cannot be reached.*
	#1 Name   Relationship   Driver's License Number   Phone Number   #2 Name   Relationship   Driver's License Number   Phone Number

	Medical Information:*
	Preferred Doctor   Address   Phone Number   Preferred Hospital   Address   Phone Number   My child has the following known allergies:   My child takes the following medication:

	List health conditions or problems:
	Health Problems   Doctor   Phone #   Current Treatment   Instructions for Club eXcel #1           #2           #3           #4

	All Club eXcel fees must be paid monthly or weekly and if changed after application is processed a $40 registration fee will be applied. Part time attendance must be paid in advance monthly on the first business day fo the month.

	Please indicate which statement applies to you:*
	Yes   No I agree to pay tuition payments in advance weekly on the first business day of the week.     I agree to pay tuition payments in advance monthly on the first business day of each month.

	If student will attend part time please list dates or days below, if known.

	Electronic Signature: Submitting this form by clicking the "Done" button will serve as your signature verifying that the information provided above is correct and that you understand and agree to abide by the Joshua ISD Club eXcel Guidelines and enrollment conditions.