Please provide the following contact information (* = required information):

Parent's First Name:	*	Hm Phone:	()-
Parent's Last Name:	*	Wk Phone:	()-
E-mail:	*		Please call me

Your child's information:

Child's First Name:	*		Boy		1st Grade
Child's Last Name:	*		Girl		2nd Grade
Birth Date (Mo/Day/Year):	/  /  *				3rd Grade
					4th Grade
					5th Grade

Enter any questions or comments you might have: