2025 Online Registration

NLRJC 2025-2026 Online Registration

Please complete all required sections and remit tuition using the payment links on this form. Additional program information can be found on the website.
Student's Preferred Name*

First NameLast Name
Student's Mailing Address*

Street Address

CityState / Province

Postal / Zip Code
Primary Parent/Guardian Name*

First NameLast Name
Primary Parent's Email*
[email protected]
Primary Parent's Phone Number*
Second Parent's Name

First NameLast Name
Second Parent's Email Address:
Please enter if they need to receive program information
Second Parent's Phone Number
Emergency Contact's Name*

First NameLast Name
Emergency Contact Phone #*
School attending--FALL 2025*
Student Birthdate*

MonthDayYear
Date
School Grade for 25-26 Year*
Student Gender*

MaleFemale
List siblings also enrolled in NLRJC Programs:
Is there any special information we should know about your student? (ex. allergens):
Permission is hereby granted to use any photograph or video likeness of the student from the cotillion program in any manner, without obtaining subsequent permission or consent and without payment of further consideration. I agree to defend, indemnify, and hold Junior Cotillion of North Little Rock, LLC, harmless from and against any claim, demand, or cause of action that I may make because of the use of any such photograph or likeness in any manner. I understand that photographs WILL NOT have the student identified by name except in the listing of the Holiday Ball and Spring Finale awardees.
Image of Student registered*

MAY be used in any print or electronic mediaMAY NOT be used in any print or electronic media
I understand the tuition policy of NLRJC; tuition payments are non-refundable.
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