*Student's Name:
*School Name:
Excused at:
*Parent Name/Guardian:
*Current E-mail:
*Main Phone #
*Mailing Address
*Student’s Birthday:
*Emergency Contact (Other than you) (Name & Phone)
*Class and time you are requesting:
Referred by:
We want all of our students to be placed in a class that is compatible to their skill level and where they will excel.
Please use the space below to tell us if you have any specific needs.

*I have read and agreed to the Liability Release & Refund Policy