Parent/Guardian Name *
Parent/Guardian Name
Mailing Address *
Mailing Address
Summer Address 1 *
Summer Address 1
Mobile Phone *
Mobile Phone
Additional Phone
Additional Phone
Please Indicate
Student 1 *
Student 1
Date of Birth *
Date of Birth
Enrollment–mark all that apply *
Student 2
Student 2
Date of Birth
Date of Birth
Enrollment (mark all that apply)
Student 3
Student 3
Date of Birth
Date of Birth
Enrollment - mark all that apply
Emergency Contact #1 *
Emergency Contact #1
Phone *
Phone
Emergency Contact #2 *
Emergency Contact #2
Phone *
Phone
Copy of Waiver and Emergency Treatment Authorization: *
Bike/Walking Permission *
Signature indicates agreement to pay tuition and agreement with waiver and emergency treatment authorization.