TAS Academy

Program Choice
Child1 Full Name

First NameMiddle NameLast NameSuffix
Child2 Full Name

First NameMiddle NameLast NameSuffix
Child3 Full Name

First NameMiddle NameLast NameSuffix
Child4 Full Name

First NameMiddle NameLast NameSuffix
Child's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Birth Date1

MonthDayYear
Birth Date2

MonthDayYear
Birth Date3

MonthDayYear
Birth Date4

MonthDayYear
Gender1
Gender2
Gender3
Gender4
Current Grade1
Current Grade2
Current Grade3
Current Grade4
Attending School
Parent 1

PrefixFirst NameMiddle NameLast NameSuffix
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Parent 2

PrefixFirst NameMiddle NameLast NameSuffix
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Fees will be paid by:
Policy Number
Authorized Pickup 1

PrefixFirst NameMiddle NameLast NameSuffix
Authorized Pickup 2

PrefixFirst NameMiddle NameLast NameSuffix
Authorized Pickup 3

PrefixFirst NameMiddle NameLast NameSuffix
Information about your child: (list allergies, restrictions, special needs, medication)
Insurance Company
Should be Empty: