Student Name:  

Home Tel: Cell:

Email: Grade:

Address:  

City:   State:   Zip:  

EMERGENCY CONTACT:

First/Last Name:  

Phone:   Relationship:  

Class Title & Code:  

Desired Start Date:  

Class Fee: $   Supply Fee: $   Total Due: $  

I Agree with the Terms and Polices:   Initials:

Please Note:

If paying by check: Please make check payable to "Linda Blevins"
and mail to: 711 Honey Grove Lane, Nipomo, CA 93444