Class #5 Morning Jul 12, 2021 09:00 am - Jul 16, 2021 11:00 am

Individual

Student's First Name *

Student's Last Name *

Student's Nickname

Student's Date of Birth (ex: 05/01/2000) *

Student's Age *

School

LYSS T'shirt Size (Adult Sizes) *

S M L XL 1X

Parent's Name *

Address *

City *

State *

Zip *

Daytime Phone *

Evening Phone

Cell Phone *

Email *

#1 Emergency Contact Name *

#1 Emergency Contact Phone Number *

#2 Emergency Contact Name

#2 Emergency Contact Phone Number

#2 Emergency Contact Cell Phone Number

How did you hear about LYSS?

#1 Emergency Contact Cell Phone Number *