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First Name

Last Name

Gender

Birthday

Student Phone

City

State

Email

Parent First Name

Parent Last Name

Parent Phone

Parent Email

Emergency Contact Name

Emergency Contact Phone Number

Billing Information

Billing Address

Billing Address 2

Billing City

Billing State

Billing Country

Billing Zip

Payment Information

Card Number

CVC

Exp. Month

Exp. Year

Deposit of $995 due at purchase; first payment of $1500 due in 30 days and second payment of $1500 due in 60 days.

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