2024 Registration Form

GEM Registration Form

Fill out the form carefully for 2024 registration. If payment doesn’t work, you can cashapp $Hattiesburggems and child's name. My contact number is (704)684-7832
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Child’s Grade Level
Parent Name
Parent E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number
Format: (000) 000-0000.
Phone Number
Format: (000) 000-0000.
Work Number
Format: (000) 000-0000.
Company
Additional Comments/Medical Concerns/ Strengths and Weaknesses
Course Registration Fees
prevnext( X )
Product Name
After school tutoring. Price includes registration and first week!

$65.00 Quantity

Total

$0.00

GEM Registration Form