Summer Enrichment 2023
Parent/Guardian Info
Name
*
First Name
Last Name
e-mail
*
Primary Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Emergency Contact (If Parent/Guardian cannot be reached)
*
Relationship to Student
*
Emergency Phone
*
-
Area Code
Phone Number
Student Info
Student Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
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Age
Grade in School 2022-2023
Please Selecti
None
Preschool
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Student email
Student Cell Phone
-
Area Code
Phone Number
New or Returning Student?
*
Returning Student
New Student
Add Student 2?
Add Student 2
Student 2 Info
Student Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Age
*
Grade in School 2022-2023
Please Selecti
None
Preschool
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Student email
Student Cell Phone
-
Area Code
Phone Number
New or Returning Student?
*
Returning Student
New Student
Add Student 3?
Add Student 3
3 Student Info
Student Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Age
*
Grade in School 2022-2023
Please Selecti
None
Preschool
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Student email
Student Cell Phone
-
Area Code
Phone Number
New or Returning Student?
*
Returning Student
New Student
Totals
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Summer Enrichment
$
125.00
Summer Enrichment Program 2023 virtual Online Enrichment
Quantity
Price
Math
0
1
2
3
4
$
125.00
ELA
0
1
2
3
4
$
125.00
Quran
0
1
2
3
4
$
125.00
All subjects
0
1
2
3
4
$
300.00
Total
$
0.00
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