Name *

Please provide the student's name that will be taking the class

First Name

Last Name

Phone 2 *

Student's cell phone number

(###)

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Name 1 *

Parent's name

First Name

Last Name

Phone *

(###)

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Name 2 *

Name of person that will be picking student up from class. If student is able to walk home on their own, please put 'self' in this space

First Name

Last Name

Phone 1 *

Phone number of person picking child up

(###)

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