Student Information
Student Name *
Student Name
Date of Birth
Date of Birth
(If under 18 yrs of age)
Address
Address
Primary Contact Information
Primary Contact Name *
Primary Contact Name
(Student or Parent/Guardian if under 18 yrs of age)
Primary Contact Cell Phone *
Primary Contact Cell Phone
Do you text?
Primary Contact Preferred Contact Time
Primary Contact Home Phone
Primary Contact Home Phone
Secondary Contact Information
Secondary Contact Name
Secondary Contact Name
(Student or Parent/Guardian if under 18 yrs of age)
Secondary Contact Cell Phone
Secondary Contact Cell Phone
Do you text?
Secondary Contact Preferred Contact Time
Additional Information
Please Specify
Emergency Contact Name
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Phone
(Known allergies, disabilities, etc.)
Please check all lessons that apply: *