Program Registration

An email address is required to complete the online registration process
BASIC INFO

The fields marked "*" are required


Was the participant previously enrolled in other KHCC programs?
Participant's First Name*
Participant's Last Name*
Participant's Middle Initial
Participant's Birthday*
Birth Country
Participant's Address*
Apt Number
City*
State
ZIP Code
Borough
Gender
Contact Email*
Contact Home Phone
Contact Mobile Phone
Participant’s Preferred Method of Contact

PARENT/GUARDIAN INFORMATION

I am the participant’s:
First Name:
Last Name:
Birth Country
Address:
Apt Number:
City:
State:
ZIP Code:
Borough:
Gender:
Contact Email:
Contact Phone:

DEMOGRAPHICS

Participant’s Ethnicity:
Applicant’s Race
(select all that apply)
How well does the Participant Speak English?
Participant’s Primary Language:
Other Languages Spoken by the Participant
(select all that apply)

Household

Household Size:
Total Gross Household Income:
$
Head of Household Type
(select all that apply)
Housing Type
Sources of Client's Household Income
(select all that apply)
Health Insurance
Is the Participant any of the following
(select all that apply)

EDUCATION

Participant is:
Current or Highest Level Completed:
Type of School
School Name:
School Address:
School City:
School Borough:
School Zip Code:
Student ID/OSIS:

Emergency Contacts

If there is an emergency, please contact the following individuals (other than parent/guardian)


Emergency Name
Email
Address
City
State
ZIP Code
Relationship to participant
Emergency Phone(s)*
Best to Call

HEALTH INFO

Health Information
(select all that apply)
Special Mentions
(select all that apply)

 
Cancel


Special Needs Program

  • Price: Free
  • Starts: Dec 31, 1969,
    Ends: Dec 31, 1969