Summer Registration Form

SUMMER INTERNSHIP REGISTRATION FORM

Easterseals of the Birmingham Area
Student Name
School
ADRS Counselor
DOB
Race
Last Grade Completed
Gender

MaleFemaleI do not wish to anser
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Alternate Phone

Area CodePhone Number
Parent/Guardian Name
Relationship
Phone Number

Area CodePhone Number
Alternate Phone

Area CodePhone Number
FOR THE PARENT OR GUARDIAN: Is there is special information we need to know concerning your child?
Easterseals of the Birmingham Area 529 Beacon Parkway West, Ste. 214 . Birmingham, AL 35209. 205.942.6277
Should be Empty:

SUMMER INTERNSHIP REGISTRATION FORM