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Class Information

Location: Google Children's Centers : Fields Day: Friday Class: PS Time: 10:20-10:50am Dates: 1/19/18 — 4/20/18 Meetings: 9 Class Price: $150.00

Student Information

*First Name:

Last Name:

Date of Birth: (mm/dd/yy)

Parent/Guardian Contact Information

First Name: Address/P.O.Box: City:

Last Name: Suite or Apt.: (optional)

State: ZIP/Postal Code: Country: Email Address:

Phone #1:

ext.

Phone #2: (optional)

ext.