Registration form

Student Name________________________________

Age_____________Date of Birth_________________

Address_______________________________________

________________________________________________

Phone Number_______________________________

School and Grade_____________________________

Any allergies or Medical Concerns?_____________________________________

Class/Classes enrolling for_____________________________________________

________________________________________________

Parent/Guardian Name______________________

Address (If different)__________________________

Phone #(If different)____________________Cell#______________

E-mail_________________________________________

Parent/Guardian Signature___________________