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Class Registration
The age of your child on September 1, 2022 determines which class they attend.
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* Indicates required question
Adult First Name:
*
Your answer
Adult Last Name:
*
Your answer
Email Address
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Home/Cell Phone
*
Your answer
Home Address
*
Your answer
City
*
Auburndale
Bartow
Fort Meade
Haines City
Highland City
Lake Alfred
Lakeland
Lake Wales
Mulberry
Polk City
Winter Haven
Other:
State
*
Florida
Other:
Zip Code
*
Your answer
Household Income
*
$0 - $9,999
$10,000 - $29,999
$30,000 - 49,999
$50,000 - up
Unknown
Ethnicity
*
African American
Asian
Caucasian
European
Hispanic
Middle Eastern
Native American
Other:
Have you attended a Family Fundamentals Class and/or an event previously?
*
Yes
No
How did you hear about us?
*
Your answer
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