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Learning to Breathe Registration Form
Thank you for registering! Please use one form per student. Your registration will be complete once you have submitted a registration form and full payment.
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* Indicates required question
Student Name
*
Your answer
Primary Email
*
Your answer
Primary Phone Number
*
Your answer
Home Address
*
Your answer
Name of Parent/Guardian #1
*
Your answer
Name of Parent/Guardian #2
*
Your answer
Student's Age
*
Your answer
Student's Grade (entering if summer)
*
Your answer
Name of Student's School
*
Your answer
May we use your child's photo for future publicity?
*
Yes
No
Please share any medical conditions (allergies, etc.) or other information about your student that you'd like us to know.
Your answer
How did you learn of this program?
*
Creative Spirit staff person
Creative Spirit Website
From a friend
Online listing
Flyer
Social Media
Newspaper
Other:
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