Student Information And Monthly Membership Dues Agreement

First Name *

Last Name *

Age

Gender *

Male
Female
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Date of birth

Address *

City *

State *

Postal code *

Email *

Cell Phone *

Mother's Name *

Mother's Cell Phone *

Mother's Business Phone

Mother's Email

Mother's Occupation

Mother's Place Of Employment

Father's Name *

Father's Cell Phone *

Father's Email Address

Father's Business Phone

Father's Occupation

Father's Place Of Employment

Emergency Contact *

Emergency Contact Primary Phone *

Emergency Contact Secondary Phone

Location

Main Location
Satellite Buder Rec Center
Satellite Hopemark Preschool
Satellite Lindbergh High School
Satellite St. John Paul II
Satellite St. Andrews
Satellite St. Gabriel The Archangel
Satellite St. Michael The Archangel
Satellite St. Raphael The Archangel
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What Are The Key Goals The Student Wants To Achieve

Credit Card Info

Card Type *

Mastercard
Visa
American Express
Discover
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Card # *

Exp. Date *

Security Code *

Membership Agreement *

I have read and agree to the membership agreement

By providing my phone number, I agree to receive text messages from the business.