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.*

    Enter code below:

    captcha