Group Winter Session

Group Winter Session Registration

January 4th-February 13th (6 weeks) *payment plans available*
Please select the days you are available: *

Monday Tuesday Wednesday Thursday Friday Saturday (MORNING ONLY)
Lessons per week *

One ($555 for 6 lessons) Two ($1,110 for 12 lessons)
Student Information
Student's Name *

First Name Last Name
Birth Date *

Month Day Year
Gender

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Information
Name *

First Name Last Name
Cell Number *
E-mail *
example@example.com
Emergency Information
Emergency Contact's Name *

First Name Last Name
Relationship
Phone Number *
Alt. Phone Number
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe. *
Is the student prescribed an inhaler? If yes, please explain any instructions. *
Should be Empty:

Group Winter Session Registration