Keane Sense of Rhythm Online Registration

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Welcome to Keane Sense of Rhythm!

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Family Last Name*

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Zip*

Primary Phone*

Additional Info

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Contact #1

Contact #1 First Name*

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Type*

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Contact #2

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Student #1

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Immunization Notes

Classes are live with zoom as an option. Let us know if you need a link to the virtual class.

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Student's First Name*

Last Name*

Birth Date

Cell #

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Student Email

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Medications (Leave blank if NONE)

Immunization Notes

Classes are live with zoom as an option. Let us know if you need a link to the virtual class.

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Student #3 (Show-Hide Details)

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Immunization Notes

Classes are live with zoom as an option. Let us know if you need a link to the virtual class.

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Medications (Leave blank if NONE)

Immunization Notes

Classes are live with zoom as an option. Let us know if you need a link to the virtual class.

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Student #5 (Show-Hide Details)

Student's First Name*

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Cell #

Additional Info

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Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Immunization Notes

Classes are live with zoom as an option. Let us know if you need a link to the virtual class.

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Address Line 1

Address Line 2

City

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Zip*

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Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

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Student #2 (Show-Hide Details)

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