Name:

Age:   Date of Birth:

Name of Parent or Guardian:

Parent's Occupation:

Home Phone:

Cell Phone:

Work Phone:

Address:

City:  State:  Zip:

Student's School:

Last Grade Completed:

Emergency Contact:

Phone #:

Number of Brothers:  Number of sisters:

CLASSES

Required: Math, Reading and Writing, Computer, Bible Study, Self-Esteem

Courses of interest (Please check)

Etiquette             Drama

Choir                  Drum Corp

Music                 Modeling

Drill Team

Private lessons upon request for a fee:

Piano                 Double Bass Violin

Violin                 Guitar

Cello                  Drums

Voice