Student Name: *     Birthdate:     Age:      Current grade:

Home Address: *  City: State: Zip:

Home telephone: *

Parent's/Guardian's name: Cell:

Email address: *

Any health concerns, ongoing injuries, or food allergies?

Emergency Information (If we can't reach parents)

Emergency name:

Telephone: Relationship to student:

* = required items

Please select the classes of interest

Parent/Legal Guardian name: * Date:

* = required items