TOTUS TUUS (Totally Yours) June 2023

CHILD'S INFORMATION

• * First Name:
• * Last Name:
• * Grade child will be attending Fall 2023 --Choose-- 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade
• * Birthdate
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Allergies or other medical concerns?
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• Fee

  Type	Fee
  1st - 6th GRADE SCHOOL FEE	$100.00
  7th-12th GRADE FEE	$25.00

Additional Information

• * Parent/Guardian Name
• * Cell Phone Number

Emergency Information

• * Do you give permission for emergency care?
• * Doctor Phone Number
• * Doctor Name
• * Emergancy Contact Name and Phone number (other than Parent or Guardian)
• Insurance Company Name
• Insurance Company Policy Number

Participant Information

You may add a maximum of 10