Class Name (required)

Class Date (required)

Student Name (required)

Male or Female (required)

MaleFemale

Student Age (required)

Parent Name (required)

Address (required)

Home Phone (required)

Cell Phone (required)

Email (required)

Please list all allergies and reactions for your child (required)

Does your child require an EpiPen?

YesNo

Does the school have the EpiPen?

YesNo

Parents Electronic Signature (required)

Date (required)

Please review and check the following:

I have other children in grade(s):

Pre-k and Kindergarten1st to 5th6th to 9th10th to 12thCollegeNetworking ProtocolOther

I would like to receive information on other classes and programs East Coast School of Protocol has available for the groups above.

YesNo Thanks