STUDENT INFORMATION Please Print Clearly!
Student First & Last Name: ___________________________________________________________
Student Mailing Address: _____________________________________________________________
City: ____________________________ State: _______ Zip Code: __________________
Student Phone: ______________________________________
Age: ____[ ] Male [ ] Female Peferred Nickname: ________________________________
Main Reason for Taking Class: _________________________________________________________
Student's School Name: ______________________________________________________________
Payment Type:
[ ] Check #______ (checks accepted until 1/11/13)
[ ] Money Order
[ ] Cash (exact change required, do not mail cash)
EMERGENCY CONTACT INFORMATION
Emergency Contact Name: ______________________________________ Phone: ______________
Relationship To Student: ______________________________________________________________
Alternate Contact Name: ________________________________________ Phone: ______________
Relationship To Student: ______________________________________________________________
