Tuesday Private Winter Session

Private Winter Session Registration

January 8th- February 17th (6 weeks) $1,020
Tuesdays 6:30-7:15

**A $30 enrollment fee is required for new students. You can pay this through paypal or by check.**
Student Information
Student's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade
MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
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.
New Student Enrollment Fee*
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Pay with PayPal
$30.00

Pay with check
Add $30 to your session total

$ Free

Total

$0.00
Should be Empty:

Private Winter Session Registration