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SPANISH

Student's name:

Date of birth:

Age:

School He/She attends:

Grade:

Home Address:

Language (s) Spoken at Home:

Mother's Name:

Mom's cell :

Email

Father's Name:

Dad's cell:

Email

Does the child have any medical conditions or allergies that you would like us to know about?

Child's Doctor:

Telephone number:

How did you hear about us?

We love to use photos and video clips in our promotiona material. May we use your child's image?

YES

NO

Parent's Signature:

Credit Card

Card Verification Code (CVV)

Expiration Date:

Billing Zip Code:

THANK YOU FOR REGISTERING!You will also receive a message to your mailbox confirming the registrationThanks again!

305-666-6609

7550 SW 57th Ave, South Miami, FL 33143, USA

stepbysteponlineclasses@gmail.com

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