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Imagication Learning: Registration Form
Basic Info
Child's Full Name
(Required)
Child's Birthdate
Month
Month
Day
Year
Child's Upcoming Grade in Fall 2025
K
1st
2nd
3rd
4th
5th
Parent/Guardian 1 Full Name:
(Required)
Parent/Guardian 1 Email:
(Required)
Parent/Guardian 1 Phone
(Required)
SMS notification when they become available?
Parent/Guardian 2 Full Name:
Parent/Guardian 2 Email:
Parent/Guardian 2 Phone:
Emergency Contact: Name
(Required)
Emergency Contact: Relationship to Child
Emergency Contact: Phone
(Required)
Location
City
(Required)
Zip Code
(Required)
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