Child InformationName *FirstLastDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Grade *2nd Grade3rd Grade4th GradeName of School *Longfellow ElementaryLowell ElementaryWashington ElementaryParent/Guardian InformationName *FirstLastEmail *Phone *Medical ConcernsEmergency Contact *FirstLastRelationship to Child *Phone *Medical Concerns *Please list any medical concerns you may have for your child, including any/all allergies. Payment Amount *Longfellow Elementary ($36)Lowell Elementary ($36)Washington Elementary ($36)Cost per location is dependent on number of classes taught. Each class costs $12 at ALL locations.PhoneSubmit