Curtis School

STUDENT INFORMATION

*Student Name:

Male/Female

(The address must match the billing address of cardholder)

* Street 1

Street 2

* City

* State

* Zip

* Home Phone:

* Parent 1 Name:

Parent 1 Cell Phone:

Parent 2 Name:

Parent 2 Cell Phone:

*Email:

*Who should we contact if class is cancelled:

If your child is registering for Homework Club, please indicate which days he/she will be attending:

* Medical Issues:

*Total Tuition:

$

Registration fee:

$10.00

*Grand Total:

Credit Card Information

* Card Type:

Select Mastercard Visa American Express

* Name on Card:

* Credit Card Number:

* Expiration Date

-- 01 02 03 04 05 06 07 08 09 10 11 12 -- 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Required Fields - *