Class Type Desired:

Student Name*

Date of Birth*:
- -

Address*

City* - State* - ZIP*
-

Phone*

Current School Attending*

Parent(s) Name(s)*

Parent(s) Cell Phone*

Parent(s) Work Phone*

Parent Email*

Seconday Email

Emergency Contact*

Primary Care Physician*

Primary Care Phone*

Any special needs or allergies:

Child may be picked up by the following person(s):

Person Completing Registration Name*


I verify the information submitted is correct.*

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