| Mother's Name: * |
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| Father's Name: |
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| Address Street 1: * |
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| Address Street 2: |
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| City: * |
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| State: |
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| Zip Code: * |
(5 digits) |
| Home Phone: * |
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| Cell Phone: |
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| Dad Cell: |
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| Other Emergency Contact/Name:: |
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| Email: * |
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| How did you hear about us? If word of mouth, from whom? * |
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| Student 1 Name * |
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| Sex |
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| Date of Birth: * |
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| Class Choice: * |
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| Special Needs/Previous Injuries: |
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| Student 2 Name |
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| Sex: |
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| Date of Birth (Student 2): |
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| Class Choice (Student 2): |
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| Special Needs/Previous Injuries (Student 2): |
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| Student 3 Name: |
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| Sex: |
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| Date of Birth (Student 3): |
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| Class Choice (Student 3): |
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| Special Needs/Previous Injuries (Student 3): |
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| Best number and time to contact you: (Office hours are M-F 9a-9p, Sat 9a-3p) * |
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| Emergency Contact: * |
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| Comments: |
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I have read and agree to the Make-up Policy |
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I have read and agree to the Late Fee Policy |
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I have read and understand the RULES & POLICIES. |
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I have read and understand the ASSUMPTION OF RISK, WAIVER OF LIABILITY and MEDICAL AUTHORIZATION and VOLUNTARILY affix my name in agreement. |
| Parent Signature: * |
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| Security Code: * |
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