Virtual Preschool Registration

1
Student Information* This field is required.Please fill out student information
Full Name
Date of Birth
2
Parent Information* This field is required.Please fill out the information of the parent who we can contact for questions and/or report progress
Parent/Guardian Full Name
Home/Mailing Address
Parent/Guardian Email address
Parent/Guardian Phone
3
Preferred Start Date* This field is required.Please select your preferred start date.
Date
Month
Day
Year
4
Virtual Program Information* This field is required.Please select your desired program so that we can place your child in appropriate classroom
5 Days (MTWThF) - $135/Week OR $525/Month
3 Days (MWF) - $100/Week OR $400/Month
Program Type (5 Days or 3 Days)
AM (10:30 AM- 12 PM PDT)
PM (2 PM - 3:30 PM PDT)
Session (AM or PM)
Bi-Weekly
Monthly
Preferred Payment Frequency
I will pick-up from Goomer Academy, San Jose, CA
Please call me to coordinate alternate pickup location
Please send it to my mailing address (I understand shipping charges will be applied)
Learning Material Delivery Preference
5
Payment Method* This field is required.
Auto Withdrawal from my bank account - Goomer Academy will send ACH Withdrawal form to your email after registration
Check in favor of "Goomer Academy"
Should be Empty: