Registration | North Rockland Online Forms

Username*

Password*

Enter Password Confirm Password

Name- Parent/Guardian*

First Last

Email- Parent/Guardian*

School*

How many children do you have in 6-12 grade?*

CHILD INFORMATION

Student Name*

First Last

Gender*

Student Email*

Age*

Date of Birth*

Home Phone 1*

CHILD 2 INFORMATION

Student Name*

First Last

Gender*

Student Email*

Age*

Date of Birth*

Home Phone 2*

CHILD 3 INFORMATION

Student Name*

First Last

Gender*

Student Email*

Age*

Date of Birth*

Home Phone 3*

CHILD 4 INFORMATION

Student Name*

First Last

Gender*

Student Email*

Age*

Date of Birth*

Home Phone 4*

ADDRESS

Address*

Street Address City State ZIP Code

PARENT/GUARDIAN/EMERGENCY CONTACT INFORMATION

Parent-Guardian #1*

First Last

Parent Email*

Place of Employment*

Hours*

Work Phone*

Cell Phone*

Parent-Guardian #2

First Last

Parent #2 Email

Place of Employment

Hours

Work Phone

Cell Phone

Alt. Contact #1*

First Last

Relationship*

Work Phone*

Cell Phone*

Address*

Street Address City State ZIP Code

PHYSICIAN/MEDICAL INFORMATION

Physician Name*

First Last

Phone*

Address*

Street Address City State ZIP Code

Dentist Name

First Last

Dentist's Phone