Course Registration Form

2025-2026 Valiente Dual Academy Registration Form
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent E-mail
example@example.com
Phone Number
Courses
How do you plan to pay $50 registration fee?

Check (Valiente Dual Academy)Credit CardPayPalEMA Step-Up
Please let us know if your student needs extra support or accommodations or has any severe allergies or conditions we need to be aware of.
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2025-2026 Valiente Dual Academy Registration Form