Registration
Boggess Elementary After School Hip Hop Classes
Event:
Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Type*
Home Phone:* Cell #: Work #:
Email:* (Emails are kept confidential)
 
Address: *
City: * State: * Zip: *
Emergency Contact Info*
 
 
Students entered below will be added to your family's account
 
Questions/Options:
Emergency Contact Name*
Emergency Contact Phone Number*
Grade*
Homeroom Teacher*
Dismissal Method: Car Pool, Walk, Pasar*
 
Additional Information:
 
Class Description, Dates & Times
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Approval To Charge Credit Card
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Medical/Publicity Waiver
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Enter your Full Name: *   
 
Other Questions/Comments:
 
Credit Card Verification:
   
Card Number: *  
Name as it appears on card: *
Nickname:
Card Expiration Month: *   Exp Year: *
Address Line 1: Address Line 2:
City: State: Zip:*