2012 REGISTRATION

St. Thomas Whitemarsh Church
Bethlehem Pike & Camp Hill Rd
Whitemarsh, PA 19034
(484) 416-0615

Thank you for your interest in Talking Stick Learning Center! Please fill out the information below and someone will be in touch with you shortly.

If you prefer, you may also download the form, fill it out and mail it to us. Click here to download a PDF of the registration form.

PLEASE NOTE: All programs and classes are subject to availability; if a class is full, we will notify you.

Child 1 First Name:

Child 1 Last Name:

Child 1 Date of Birth:

Child 1 Age:

Child 2 First Name:

Child 2 Last Name:

Child 2 Date of Birth:

Child 2 Age:

Parent 1 First Name:

Parent 1 Last Name:

Parent 1 Cell:

Parent 1 Email:

Parent 2 First Name:

Parent 2 Last Name:

Parent 2 Cell:

Parent 2 Email:

Home Phone:

Address:

City:

State:

Zip:

Emergency Contact Name:

Emergency Contact Phone:

Allergies:

Permission to use child's image in promotional materials:

Yes

Is there anything else you'd like to tell us about your young person?: