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 November *

Week of Nov 16th Week of Nov 23rd Week of Nov 30th
Day of the Week (Select Day or Days interested) *

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?
Should be Empty:

Signing Up Grades 2-8!