Registration |Proud 2 Be Me: Learning Center

top of page

Use tab to navigate through the menu items.

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 * Required

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

Upload File

Upload supported file (Max 15MB)

bottom of page