Class Type Desired:

    Student Name*

    Date of Birth*:
    - -


    City* - State* - ZIP*


    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:




    Please complete the form above and click Send.  Once you have sent the form, you may pay the class tuition online by clicking the Buy Now button. You will be redirected to Paypal’s secure site to complete payment.