Child’s Name ______________________________________________________

Nickname: _____________________________________________________

Home Phone ( ) _______________________ ( )

_______________________ FAX

Address ______________________________________________________

City __________________________________________

State _________________ Zip _____________

Student Email ______________________________________________________

Gender F M Date of Birth ___ / ___ / ___

Age in 06/08 _______ Grade Completed 05/08 _______

Please include a headshot (or snapshot) and resume, if you have one.

Parents’ Name _______________________________________

Home Phone ( ) ________

Work Phone________________________

Cell ( ) ________________________

FAX ( ) ________________________

Email _________________________________________________________

Address (if different) ______________________________________________________