Vivian Kaeppel Elem. Math Registration Form
4th Period (1:30 - 3:00 p.m.)
Student Name *
Student Date of Birth *
MM
/
DD
/
YYYY
Student Grade Level
Student Home Address *
Student Email (if applicable) *
Student Cell Phone (if applicable) *
Special Needs or Medical Conditions (Please specify)
Father *
Mother *
Parent(s)' Address (if different from above) *
Home Phone Number *
Mother's Cell Number *
Father's Cell Number *
Mother's Work Number *
Father's Work Number *
Emergency Name and Phone Number *
Payment Options *
Choose (1) Frequency and (2) Method of Payment
Required
Submit
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