Baker's Dozen Academy LLC

 

Class Registration form

 

 

Personal Information:

 

Child/Children's name________________________________________________________

 

Child/Children's age__________________________________________________________

 

Parent's name _______________________________________________________________

 

Address ___________________________________________________________________

 

Home Phone ___________________________ Cell ________________________________

 

Email________________________________________________

 

 

School Information:

 

Teacher and grade level, (If applicable) ___________________________________________

 

School Name _______________________________________________________________

 

Person Picking up Child ______________________________________________________

 

Who else may pick up your Child? ______________________________________________

(If other than Parent, proper ID required)

 

Date and Class description ____________________________________________________

 

Total Fee of class/classes ______________________________________________________

 

Emergency contact's (other than above-named parent)

 

Emergency contact#1: ________________________ Phone# _________________________

 

Emergency contact#2: ________________________ Phone# _________________________

 

Are there any medical conditions that we should be aware of? __________________________

 

Receipt of your payment constitutes agreement to the terms of the registration and waiver form.

 

If paying by check, make check payable to: Baker's Dozen Academy