Community Class Registration
Student Contact Inforamation
Student's First Name *
Your answer
Student's Last Name *
Your answer
Date of Birth
MM
/
DD
/
YYYY
Age
Your answer
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:
Your answer
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:
Your answer
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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