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Student's Name*
Address
City/Zip*
Date of Birth*
School Grade for 2018-2019*
School Attending*
Email Address*
Parent(s) Name(s)*
Primary Phone Number*
Secondary Phone Number*
What Type of Care Do You Need?
Allergies/Medical Conditions
How Did You Hear About Us?*
Dance/Karate Registration
Age
Prior years of dance/karate experience
Mother's Name
Mother's Cell Number
Father's Name
Father's Cell Number
What class(es) are you enrolling in? *
How did you year about us?
Emergency Contact Other Than Parent
Emergency Contact Phone Number
Allergies/Medical Conditions*