Community Class Registration
Years in Attendance
Student Contact Inforamation
Student's First Name
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Student's Last Name
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Date of Birth
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/
DD
/
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Age
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Address
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City
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Zip
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Phone
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Email
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Class Information
Day
Student Health Information
List any allergies or special health needs:
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Check any disabilities that apply
Student is able to take care of basic needs (ie using the bathroom, taking medication, etc.)
Student will be attending with an aide/ assistant (including a parent):
Aide/ Assistant's name:
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Emergency Contact
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Emergency Contact Phone
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Student Demographics
School Currently Attending
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Do you qualify for free or reduced lunch?
Do you receive social security benefits or wavier?
Student Ethnicity
Student Gender
Referred to ArtMix Community Classes by (name, phone, agency):
Your answer
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