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Course Enrollment Form

Child 1

Child's Name

First name *

Last name *

Preferred name

Date of birth *

Month

Day

Year

Current grade level *

Allergies *

Special needs

School *

Track *

Parents

First Parent

Name *

Address *

City *

State *

Zip *

Work phone
with Area Code

Mobile phone
with Area Code

Home Phone
with Area Code

E-Mail Address *

Second Parent

Name

Address

City

State

Zip

Work phone
with Area Code

Mobile phone
with Area Code

Home Phone
with Area Code

E-Mail Address

Emergency Contact *

Relationship

Emergency Contact Address

Emergency Contact Phone
(with Area Code)

Emergency Contact E-Mail *

Primary Physician *

Primary Physician's address *

Office Telephone Number
with Area Code *

Insurance Carrier *

Insurance ID# *

Insurance Company Phone
with Area Code *

Policy Holder *

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