Registration

Select Class:

Preferred Day/Time:	(e.g. Tuesdays 09:30)
Preferred Location:

Parent's First Name:
Parent's Last Name:
Address Line 1:
Address Line 2:
City:
State/Province:
Zip/Postal Code:
Email Address:
Home Phone Number:	- -
Work Phone Number:	- -
Cell Phone Number:	- -

Alt. Contact Person:
Alt. Contact Phone:	- -

Child's First Name:
Child's Last Name:
Child's Current Age:	months years
Child's Birthdate:	(MM/DD/YYYY)

List any allergies or medical issues of which the teacher should be aware:


How did you hear about us?:

Other:

Question/Comment: