Jefferson Middle School Nights Pre-Registration

This form must be completed in its entirety even if your child has attended in the past.

You can get your Middle School Night season pass from the YPR main office at 299 Decatur Road!

Question Title

* 1. Your Child

Child's First Name

Child's Last Name

Child's Preferred Name (if different)

Question Title

* 2. Child's Sex

Male

Female

Other (please specify)

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* 3. Child's Date of Birth

MM/DD/YYYY

Date

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* 4. Child's Current Grade (as of September 2022)

Pre-K

Other (please specify)

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* 5. Child's School (as of September 2022)

Franklin Middle

Hoover Middle

St. Amelia

Charter School for Applied Technologies

Other (please specify)

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* 6. Child's Primary Address

Address

City/Town

State

Zip

Phone Number

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* 7. Primary Parent/Guardian

First Name

Last Name

Address

City/Town

State

Zip

Cell Phone Number

Email Address

Employer

Work Phone Number

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* 8. Secondary Parent/Guardian (if applicable)

First Name

Last Name

Address

City/Town

State

Zip

Cell Phone Number

Email Address

Employer

Work Phone Number

Please list AT LEAST two people (other than the parent/guardians listed above) to contact in case of an emergency if a parent
cannot be reached.

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* 9. Emergency Contact #1

First Name

Last Name

Relationship to Child

Phone Number

Alternate Phone Number

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* 10. Emergency Contact #2

First Name

Last Name

Relationship to Child

Phone Number

Alternate Phone Number

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* 11. Emergency Contact #3 (optional)

First Name

Last Name

Relationship to Child

Phone Number

Alternate Phone Number

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* 12. Please let us know of any medical conditions, allergies, behavioral concerns, etc. that our staff should be aware of

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* 13. How did you hear about Middle School Night?

Family member/friend

TTYPR website

Social media

Flyer from school/school district referral

TTYPR e-newsletter

Live nearby

Newspaper

Have attended in the past

Other (please specify)