Vivian Kaeppel Economics Registration Form
2nd Period (10:00 - 11:30 a.m.)
Student Name *
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Student Date of Birth *
MM
/
DD
/
YYYY
Student Grade Level
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Student Home Address *
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Student Email (if applicable) *
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Student Cell Phone (if applicable) *
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Special Needs or Medical Conditions (Please specify)
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Father *
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Mother *
Your answer
Parent(s)' Address (if different from above) *
Your answer
Home Phone Number *
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Mother's Cell Number *
Your answer
Father's Cell Number *
Your answer
Mother's Work Number *
Your answer
Father's Work Number *
Your answer
Emergency Name and Phone Number *
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Payment Options *
Choose (1) Frequency and (2) Method of Payment
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