Registration Form

Date: ______________

Student’s Name: 1. ______________________________ Age _____ Birth Date _________M/F

                        2. ______________________________ Age _____ Birth Date _________M/F

        3. ______________________________ Age _____ Birth Date _________M/F

Address:               Street _________________________________________________________

                           City   _____________________________State _______ Zip ______________

                        Home Phone ____________________ Work Phone ____________________

  1. Parent’s Name: _________________________________________________

     Primary Cell: _______________ Email Address: ________________________

  1. Secondary Contact Name: _________________________________________

Primary Cell: _______________ Email Address: ________________________

How did you hear about us? _______________________________________

Referral/Friend Name ____________________________________________

Emergency Contact:

Name ____________________________________ Phone _______________

Relationship to __________________________________________________

Office use only

Free Trial Date _________                   Amount Due: $__________ EF

Start Date _____________                                     $__________ Current Month

Class _________________                                      $__________ Other

                                                                     $__________ Total