Parent’s Name *
Parent’s E-Mail *
Parent’s Cell Phone *
Home Phone
Child’s Age *
Child’s Gender
Do your child have any injuries? *YesNo
If YES, please explain
Does your child have any medical conditions we should be aware of? *YesNo
What are you hoping your child will get out of this class? *
Has your child ever been assaulted or know someone who has? (optional)YesNo
What grade is your child in? *
Is there anything else you would like to let us know?
