Date of Birth:

Current Grade Level:

Parent or Guardian 1 Name:

Parent or Guardian 2 Name:

email address(es):

Phone number(s):

School (pls circle or write in): St. Pius   Roy Cloud   Woodland   ..........

Requesting Class (pls. circle): At School  /  Pre-K  / Tutoring  /  CNED  /  Beginner French / Advanced French / Online Class / Camp / Other