Registration

Fill out the form below to submit your registration. A $75 annual registration fee is required for each student, and can be paid after submitting this form or added to your bill.

Student's Name

First Name

Last Name

Parent's Name

First Name

Last Name

Primary Phone Number

(###)

###

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Secondary Phone Number

(###)

###

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Email

Student's Date Of Birth

MM

DD

YYYY

School / Grade

Preferred Lesson Times (Please list 2-3 options)