Students Name

Date of birth     Age    Grade Completed

Parent/Guardian Name(s) 

Address 

City    State  Zip

Email

Day Phone      Evening Phone 

Cell Phone 

Emergency Contact     Emergency Phone

My Child’s interests (please check ONE preference)

Dance         

Art

My Child   can  cannot    be photographed.

My Child can be picked up by:

Allergies/Health Condition:

Medications

I would be willing to chaperone an event yes   no

I would be willing to drive for an event  yes   no