REGISTER ONLINE

North Little Rock Junior Cotillion

Printable Form

COMPLETE this digital registration form AND pay online using the links below in order to complete registration

* Indicates required field

Student's Preferred Name *

First

Last

Student: *

Male Female

Select school grade for FALL 2023 *

School attending--FALL 2023 *

Student's Date of Birth *

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 photograph WILL NOT have the student identified by name except in the listing of the Holiday Ball and Spring Finale awardees. Images of this student may be used in print or electronic media coverage *

YES, Image may be used NO, Image may NOT be used

Student's Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Parent Name, Email, and Phone Number *

2nd Parent's Name, Email, and Phone Number *

Emergency Contact NAME, RELATIONSHIP, PHONE NUMBER *

I agree to receiving marketing and promotional materials *

Submit

Tuition Policy: Tuition Payments are NON-REFUNDABLE

Cotillion Club (5th grade)

$139.00

Pay Tuition

6th Grade Registration

$209.00

Pay Tuition

7th Grade Registration

$209.00

Pay Tuition

8th Grade Registration

$139.00

Pay Tuition