EmailMe Form - [arch] 2022/23 Leg Up Equestrian- Registration

Student Name *

First Last

Preferred Name (or nickname) *

What name would you like us to use for class?

birthdate *

mm/dd/yyyy

age *

gender *

School Grade

*select student's grade for 2022-20223 school year.

Home School?

yes

no

Contact Info

Parent/Primary contact *

First Last

Email *

We will contact you ASAP!

primary/cell *

### - ### - ####

alternate/day phone

### - ### - ####

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

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