DDJB

Parent and Child Information

Parent/Guardian First Name(required)
Parent/Guardian Last Name(required)
Email(valid email required)
Confirm Email(valid email required)
Primary Phone(required)
Secondary Phone
Child's First Name(required)
Child's Last Name(required)
Sex
MaleFemale
Child Date of Birth(required)
Address(required)
City(required)
State(required)
Zip(required)

Emergency Information

Emergency Contact Name(required)
Emergency Contact Primary Phone Number(required)
Emergency Contact Backup Phone Number
Allergies or Intolerance to Food, Medication or other Special Needs
Child's Physician Name(required)
Child's Physician Phone(required)

Class Choice. Cost shown is per month.

Week(s) - $150 per week
June 12-15June 19-22July 10-13July 17-20

Electronic Signature

Electronically sign by typing first and last name(required)

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