Afterschool Ceramics Registration

Student Name*
Date of Birth*
Date Format: MM slash DD slash YYYY
Age
School Name*
Grade*
Student Address*
Street Address Address Line 2 City State ZIP Code
Student Cell Number
Student Email
Parent/Guardian Name*
Parent Email*
Parent Cell Number*
Parent Other Phone Number*
Emergency Contact Name*
Emergency Contact Phone*
Winter Session*
Winter Session starts January 7, 2020
Total
$0.00