Hybrid Learning at Xperiment VR

www.XPERIMENTVR.com

PLAY - LEARN - DISCOVER
Signing Up Grades 2-8!

Single Day Options Available!
Student Request Form

We are limiting the enrollment to a total of 12 students split into two groups.
Please submit your details below for full details and pricing.
Parents Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parents Email *
example@example.com
Mobile Number *
Phone Number
Work Number
Student Name *

First Name Middle Name Last Name
Birth Date

Month Day Year
Gender
Grade Entering *
School Child Attends *
Please select possible weeks you are interested in September *

Week of Sept 7 Week of Sept 14 Week of Sept 21 Week of Sept 28
Please select possible weeks you are interested in October

Week of Oct 5 Week of Oct 12 Week of Oct 19 Week of Oct 26
Day of the Week (Based on your cohort) *

Monday Tueday Wednesday Thursday Friday
How did you hear about our program? *
Please let us know if there are any questions or comments you have for us?
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Signing Up Grades 2-8!