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Jan 3 - 24 2022 Monday to Friday Class Registration Form
Student Registration and Information
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* Indicates required question
Email
*
Your email
Last Name
*
Your answer
First Name
*
Your answer
Middle Name
*
Your answer
Street Address
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
Date of Birth eg, 01-31-04
*
Your answer
Student's WRHS email address
*
Your answer
Student Cell #
*
Your answer
Parent 1 name
*
Your answer
Parent 1 email address
*
Your answer
Parent 1 Cell #
*
Your answer
Parent 2 name
*
Your answer
Parent 2 email address
*
Your answer
Parent 2 cell #
Your answer
Is your parent taking our Parent/Guardian Class?
*
Yes
No, they already took one in the past five years
Required
If your parent took the parent class already please supply the school name and date of class attended
Your answer
Learners Permit Number if you already have one.
Your answer
Issue date of your Permit
MM
/
DD
/
YYYY
Amount you are mailing today (min amount $400)
*
Your answer
Check or Money Order Number
Your answer
Medical conditions or medications we should know about
*
Your answer
A copy of your responses will be emailed to the address you provided.
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