Fillable REGISTRATION FORM (For Our 28 Session Since 1992)

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REGISTRATION FORM (For Our 28 Session Since 1992)

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“
We Won’t Tell You What To Think, We Simply Insist That You Do.”
REGISTRATION FORM
(For Our 28
TH
Session Since 1992)
Name: Age: _
(Please Print)
Address: _
_
Phone: _
School: Grade: _
Parent or Guardian: _
Emergency Phone Number: _
D O B: / /
Email Address: _
I’m here because _
____
______
_______________________________________________________
_______________________________________________________
2101 Shadyside Avenue Dr. Demitri C. Kornegay,
Suitland, Maryland 20746 MUC Program Manager
(240
) 4
55-
4208
Mildred Louise Lyles,
www.galilee-cdc.or
g
GCDC Executive Director
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REGISTRATION FORM (For Our 28 Session Since 1992)

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Completed 31 March 2022

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