Please fill out this registration form to help us know you better and know what to do in case of an emergency.  We look forward to meeting you!

Your Name:

Email:

Phone Number:

Names of Adult Students:

Street Address:

City:

State:

Zip:

Are you in need of transportation?
YesNo

Emergency Contact Name and Phone Number:

What country are you from?

What is your primary language?

Which of the following classes will you or your family be joining:
Adult EnglishCitizenshipK-12 TutoringPreschoolChildcare

Will you be joining us for evening Compass, daytime Compass, or both?
EveningDaytimeBoth

Do you have children that will be joining us?
YesNo

If yes, please provide us with the following information:

Child's Name:
Birth Date:
BoyGirl
Grade:
School:

Child's Name:
Birth Date:
BoyGirl
Grade:
School:

Child's Name:
Birth Date:
BoyGirl
Grade:
School:

Child's Name:
Birth Date:
BoyGirl
Grade:
School:

Child's Name:
Birth Date:
BoyGirl
Grade:
School:

Child's Name:
Birth Date:
BoyGirl
Grade:
School:

Child's Name:
Birth Date:
BoyGirl
Grade:
School:

Please explain any medical concerns or allergies that we should know about?

Do we have your permission to use photos of you and your family for Compass Materials?
YesNo

If your child is injured or sick and Compass cannot reach you, do you give permission for the staff and volunteers to care for him or her and contact the doctor or hospital directly.
YesNo

Do you give your permission for Compass staff to speak directly with your child’s school in order to better support them?
YesNo

Is there anything else you’d like us to know?

How did you find out about us?
Internet searchFacebookA friendOther

I verify that the information I have provided on this form is true to the best of my ability.