Parent/Guardian Name*

First Last

Email*

Phone*

I'm interested in:*

Preferred Academie Location*

How did you find out about us?*

Referral Name

Other, please specify how you found out about Panache.

Student Name

Grade*

Start Date*

Pick Up Required?*

Elementary School*

Schedule*

Please select the number of days required per week. Multiple days can be selected by using the CTRL key or the Command Key for Apple users

Additional Comments