Summer Program Registration Form

Registration Form

Never Stop Learning, Progressing, & Having Fun
Please complete the complete form. The program will start June 24, 2025. A one-time, non-refundable registration deposit may be applicable and required.
Parent's Name

First NameLast Name
Child's Name

First NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Mobile Number

Area CodePhone Number
Phone Number

Area CodePhone Number
Work Number

Area CodePhone Number
PROGRAM INFORMATION
Please select if your child will attend two or three days per week

Child will attend 2 days/week (Tues & Thurs)Child will attend 3 days/week (Tues, Weds & Thurs)
Learning Coach-(person that wlll support child during the sessions)
How did you hear about us?
Please contact me

Yes
Address if different from above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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Registration Form