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Claude Watson Registration Form

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Please fill in the form below and click “Pay Now”. The cost for the program is $120. The program is 8 weeks in length.

Thank you for supporting your child’s development and education with QSLA programming!

Student Name (required)

Grade (required)

Parent/Guardian Name (Title (Mrs., Ms., Mr., Dr.) First Name, Last Name) (required)

Parent/Guardian Email Address (required)

Phone number (required)

Has the student ever been diagnosed with a physical condition we should be aware of?

Yes

Please list any medical condition(s), including any requiring medications (ex. Diabetes, Asthma, Seizures)

Emergency Contact

Emergency Contact Name

Emergency Contact Phone Number

Relationship to the Student

Payment

Choose the session below

Claude Watson Wednesdays, January - March 2020 – $120

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