STEMpals Student Registration Form

STEMpals Student Registration Form
Student Name*

First NameLast Name
Age*
Grade Level (2nd-8th Only + Algebra 1)*
Email the Student will use to Participate in Class*
example@example.com
Parent Name*

First NameLast Name
Parent Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?*
Select How Many Classes You Would like Your Student to Join

1 Class Monthly Payment

Monthly Class Payment for 1 Class (9 months)

$19.99 for each month

2 Classes Monthly Payment

Monthly Class Payment for 2 Classes (9 months)

$39.99 for each month

3 Classes Monthly Payment

Monthly Class Payment for3 Classes (9 months)

$59.99 for each month

4 Classes Monthly Payment

Monthly Class Payment for 4 Classes (9 months)

$79.99 for each month

Email

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

What Classes Would Your Student Liked to be Placed in*
If you have any questions or concerns please write them below:
Should be Empty: