Coding Classes Registration Form

Blank Form (#27)

Child's Name

Date of Birth

Parent/Guardian Name

Phone Number

Course Name

How did you hear about us?

Does the candidate have any special requirements or disabilities?

Yes

Please Explain

(see codes below)

Special needs	Code
Sight	S
Hearing	H
Learning	L
Mobility	M
Other	S
Candidate prefers no statement	O

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