South Franklin Community Center, Provo, Utah

General Registration

Parent First Name(*)

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Parent Last Name(*)

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Address (*)

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City(*)

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State(*)

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Zip Code(*)

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Primary Language

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Phone Number

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Can we text you about new resources that may be available(*)

Yes No

You must indicate yes or no to move forward in the registration.

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What is your preferred method of contact

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What is your Facebook Name

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If we can not reach you through preferred method of contact we will reach out through facebook

The next following questions are used to help fund the programs at the South Franklin Community Center. All information that is given will be confidential.

What is your sex

FemaleMale Prefer not to say Invalid Input

What is your race or ethnicity

Native American or Alaskan Native

African American

Hispanic or Latino

Native Hawaiian/ Pacific Islanders

Asian

African Nationals/ Caribbean Islanders

Middle Eastern

White (Non Hispanic/European American)

Other

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What is your Country of birth

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What is your family income

$0-$10,000

$10,001-$20,000

$20,001-$30,000

$30,001-$40,000

$40,001-$50,000

More than $50,000

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What is your highest level of education

Elemenatry of junior high school

Some high school

High school dimploma or GED

Trade/Vocational Training

2-year college degree (Associates)

4-yeay college degree (Bachelor's)

Master's degree

PhD or other advanced degree

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What is your native language

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Please indicate your marital status

Single

Partnered

Married

Divorced

Widowed

Seperated

Prefer not to say

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What is your Spouses or Partners country of birth

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What is your Spouses or Partners highest level of education

Elementary or junior high school

Some high school

High school diploma or GED

Trade or Vocation training

Some college

2-year college degree (Associates)

4-year college degree (Bachelors)

Masters degree

PhD or other advanced degree

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What is your Spouses or Partners first name

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What is your Spouses or Patners last name

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What is you Spouses or Partners date of birth

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What is your Spouses or Partners phone number

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What is their sex

Male FemalePrefer not to say Invalid Input

Who will be your emergency contact

Spouse/PartnerOther Invalid Input

What is your emergency conacts complete name

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*Please provide an emergency contact that is local*

Contacts relationship to you

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What is your emergency contact's phone number(*)

You have to put in an emergency contacts phone number to continue.

Do you have a computer or internet access

YesNo Invalid Input

Do you have children

Yes

Yes, but they will not be participating in South Franklin programs

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How many children do you want to enroll

0123456 Invalid Input

Child 1 Name

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Child 1 date of birth

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Child 1 sex

MaleFemalePrefer not to say Invalid Input

How well does Child 1 speack English on a scale of 1 to 5 - 1 being not at all and 5 being fluently

12345 Invalid Input

Child 2 name

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Child 2 date of birth

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Child 2 sex

MaleFemalePrefer not to say Invalid Input

How well does child 2 speak English on a scale of 1 to 5 - 1 being not at all and 5 being fluently

12345 Invalid Input

Child 3 Name

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Child 3 date of birth

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Child 3 sex

MaleFemalePrefer not to say Invalid Input

How well does child 3 speak English on a scale of 1 to 5 - 1 being not at all and 5 being fluently

12345 Invalid Input

Child 4 name

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Child 4 date of birth

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Child 4 sex

MaleFemalePrefer not to say Invalid Input

How well does child 4 speak English on a scale of 1 to 5 - 1 being not at all and 5 being fluently

12345 Invalid Input

Child 5 Name

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Child 5 date of birth

Invalid Input

Child 5 sex

MaleFemalePrefer not to say Invalid Input

How well does child 5 speak English on a scale of 1 to 5 - 1 being not at all and 5 being fluently

12345 Invalid Input

Child 6 Name

Invalid Input

Child 6 date of birth

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Child 6 sex

MaleFemalePrefer not to say Invalid Input

How well does child 6 speak English on a scale of 1 to 5 - 1 being not at all and 5 being fluently

12345 Invalid Input

South Franklin Code of Conduct

I have read and agree to the Code of Conduct(*)

Please select if you understand and agree to South Franklin's Code of Conduct

You must agree to the Code of Conduct to participate at the South Franklin Community Center

South Franklin Liability Agreement

I have read and agree to the Liability Agreement(*)

Please select here if you understand and agree to the Liability Agreement

You must agree to the liability agreement to participate at the South Franklin Community Center

I agree to allow use of my image and/or that of the named minor(s), which may be captured through video, photo, digital camera or other media, for South Franklin Community Center promotional materials and publications. I have had all my questions answered to my satisfaction, and I voluntarily agree to participate and/or let my child participate in an activity at the South Franklin Community Center.

(*)

I agree

I disagree

You must choose whether you agree or disagree to submit registration.

Submit