Student’s full name:

Today’s date:

Student’s age:

Student’s birth date:

Parent/Guardian’s name:

Contact Information:

Cell: _____________________ Home: _____________________ Work: __________________

Email address: _________________________________________________________________

Mailing Address: ________________________________________________________________

Emergency Contact: Name: _______________________________ Phone: ________________

Relationship: ___________________________________________________________________

Class Title

Session

Class

Date

Class

Time

Class

Fee

Supply

Fee

As payment in full for the above classes, I submit (cash or check)

$

I understand I will receive confirmation of class registration by mail or email,

and refunds will be granted only if the session is canceled or White Bluffs finds

another child to fill the place.

Parent/Guardian Signature Date

Please list any allergies, health issues or other areas of concern, so that we may give your

child appropriate attention. Snacks may be served in some classes.