Kids Returning Student Registration – Ages 11-13

Student Information

Student Name*

Date of Birth*

Age*

Parent / Legal Guardian Information

Parent / Legal Guardian Name*

Address*

City*

Postal Code*

Telephone*

Cell*

Work Phone

Email Address*

Emergency Information

Emergency Contact Name*

Emergency Contact Telephone*

Emergency Contact Cell*

Health Information

Known Allergies / Health Information

Class Level / Age Group: Ages 11-13

Class Schedule:
Fridays 4:30 PM – 5:30 PM (Fixed Schedule)

Payment Terms
The semester tuition is $850 due at the beginning of the semester.

Agreement
By signing this form, you agree to all the terms indicated above.

Student or Parent/Legal Guardian Signature (Type Full Name)*

Date*