Lesson Registration Form

Date

Student's Name

Preferred Lesson Day

Custodial Parent's Name(s)

Home Address

Home Phone

Work Phone

Cell Phone

Email Address

Other than custodial parents, list up to (2) person's names and contact phone who are allowed to pick up your child:

Student's Age

Student's Date of Birth

Entering Grade

School Attending

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List any allergies to any medications, foods, or any other type of allergy:

List any medications currently taking, daily dosage and for what medical condition:

List any physical, behavioral, or learning limitations or special needs: