Summer Intensive Form

Summer Intensive Form
The Summer Intensive will be from July 8th-31st 2024

Ages 6-13 years old

Registration Fee $65

Flat Rate $90

Ages 3-5 Monday/Wednesday 5:30pm-6:30pm

Ages 6-8 Monday/Wednesday 6:30pm-7:30pm

Ages 9-13 Tuesday/Thursday 6:00pm-7:00pm

Ages 13-18 Tuesday/Thursday 7:00pm-8:00pm

Location: 212 NE 59th Terr. Miami,FL 33137
Child Information
Child's Name

First NameLast Name
Birth Date

MonthDayYear
Grade
MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information
Name

First NameLast Name
Home Number

Area CodePhone Number
Cell Number

Area CodePhone Number
E-mail
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the child prescribed an inhaler? If yes, please explain any instructions.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Should be Empty: