Childs Last Name

Childs First Name

Child's Date of Birth

Parent/Guardian #1 Name

Parent/Guardian #2 Name

Parent/Guardian #1 Phone Number:

Parent/Guardian #2 Phone Number:

Address

Emergency Contact Name:

Emergency Contact Phone #:

Person Responsible for Tuition

Address

Parent/Guardian #2 Phone Number:

The adult bringing the child to class and that signs this form is responsible for the payment of charges

Person Responsible for Tuition

Address

Parent/Guardian #2 Phone Number:

Your Signature

Clear