STEMpals Student Registration Form
Student Name
*
First Name
Last Name
Age
*
Grade Level (2nd-8th Only + Algebra 1)
*
Email the Student will use to Participate in Class
*
example@example.com
Parent Name
*
First Name
Last Name
Parent Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
How did you hear about us?
*
Select How Many Classes You Would like Your Student to Join
*
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next
( X )
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:
Submit
Should be Empty: