Registration |Proud 2 Be Me: Learning Center

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Child's First Name

Child's Last Name

Address

City/Town

State

Zipcode

Gender

Age

Does this child have any medical conditions, physical limitations, allergies or special needs?

To better serveyour child, please indicate if he/she has been diagnosed with any of the following

ADD/ADHD

Convulsions

Bleeding/Clotting Disorders

Autism

Aspergers

Fragile X

Cerebal Palsy

Bipolar Disorder

Tourettes

Rhett Syndrome

Down Syndrome

Chronic Health Problems

Asthma/ Sever Allergies

Diabetes

Heart defect/disease

Other

None

If you selected other, list below.

If you have your child's immunization records, please upload

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