Registration

Parent Registration

Talk Tools Parent Registration

Parent Name

E-mail

Phone

Child Name

Child's Birthdate

Grade

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School

School District

Regional Center

Club 21 Member?

Yes
No
Unsure

How did you hear about Club 21?

Parent Talk Tools Registration:

Member Talk Tools Fee $10 + Annual January Member Fee: $45
Non-Member Registration Fee: $75
Talk Tools Registration: $10 (For new parents with child 1-yr and younger)

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged