Flexidragon and Egg Workshop Registration

Participant Name

First NameLast Name

School Attending

Age

Grade

Please note that we are collecting information for the next three questions to meet the requirements for grant funding received through the State of Maryland.

Home Zip Code

Number of Individuals in Household

Household Income (2 people)

Household Income (3 people)

Household Income (4 people)

Household Income (5 people)

Household Income (6 people)

Household Income (7 people)

Household Income (8+ people)

Does the student have any medical needs/special considerations?

Allergies (food, environmental):

Medical Conditions or Special Considerations:

Parent or Guardian Name

First NameLast Name

Parent or Guardian Email Address

example@example.com

Parent or Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Relationship

Is there an additional emergency contact different from parent or guardian listed above?

Emergency Contact Name

First NameLast Name

Emergency Contact Email

example@example.com

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Relationship

Class:

Flexidragon drop-in workshop, 6PM-8PM, October 9

$25.00

Add extra to support our programs

Optional; not tax deductible

If you would like to make a tax deductible donation, there will be a link on the purchase confirmation page.

$5.00 Quantity

Total

Payment Methods
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Flexidragon and Egg Workshop Registration

Class:*

Class: