Please send this with your Registration Form / Times Available Sheet / check. Thanks!

Student Information Sheet

                          Date: _________________

Student name:_______________________________________________________

Student E-mail Adress:_________________________________________________

Phone No:_________________Birth Date:___________Age on Mar. 1, 2015:______

School District:_______________________________________________________

School________________________________________Grade in school:________

Home Address:______________________________________________________

    ____________________________________________________________

    ____________________________________________________________

Referred by:_________________________________________________________

Mother’s name:______________________________________________________

E-mail address:______________________________Fax:_____________________

Occupation:_________________________________________________________

Place of Business:____________________________________________________

Business Phone No:___________________Cell Phone_______________________.

Father’s name:______________________________________________________

E-mail address:______________________________________________________

Occupation:_________________________________________________________

Place of Business:____________________________________________________

Business Phone No:____________________Cell Phone______________________.

Additional Info:  (please continue on the back of this page, if necessary.)