Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Mobile

Instructors often find it helpful to have student mobile numbers to coordinate office hours and course logistics. This is completely optional and leave it up to the discretion of each parent.

(###)

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Cell Phone Communication

I am okay with instructors messaging or calling my child.

I am not okay with instructors messaging or calling my child.

Name 1

First Name

Last Name

Phone 1

(###)

###

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Opt out of receiving text messages

I don't want to communicate via text message